NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Health promotion
Correct answer: A
Rationale: Primary prevention involves activities that promote wellness or prevent illness or injury. Educating parents about safety measures in the home aims to prevent injuries, making it a primary prevention strategy. Secondary prevention focuses on early detection and intervention in diseases or injuries. Tertiary prevention involves reducing disability and promoting optimal functioning in relation to a disease or injury. Health promotion encompasses activities that enhance a client's overall health and well-being. In this scenario, educating parents about safety in the home falls under primary prevention as it aims to prevent injuries before they occur.
2. When meeting nurses for the first time, a new nurse manager makes eye contact, smiles, initiates conversation about their previous work experience, and encourages active participation. This behavior is an example of
- A. aggressiveness
- B. passive aggressiveness
- C. passiveness
- D. assertiveness
Correct answer: D
Rationale: The nurse manager is demonstrating assertive behavior by confidently engaging with the nurses through eye contact, smiling, and encouraging participation. This behavior shows a balance between expressing her own opinions and respecting others. Aggressive behavior would involve dominating or embarrassing others, while passive behavior is characterized by being timid or nervous. Passive-aggressive behavior is indirect and manipulative, which is not demonstrated in this scenario.
3. A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?
- A. Insert a gloved finger into the mother's vagina to feel for cord compression
- B. Position the mother so that her hips are elevated
- C. Notify the registered nurse
- D. Perform a vaginal examination on the mother
Correct answer: B
Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.
4. A nurse is assisting with data collection regarding the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform?
- A. Go to the bathroom without help
- B. Dress himself appropriately
- C. Put on and tie his shoes
- D. Align two or more blocks
Correct answer: A
Rationale: By 24 months of age, a child can perform various activities. While the child may be able to put on simple items of clothing, distinguishing front from back might still be a challenge. They may also be able to zip large zippers, put on shoes, wash and dry their hands, align two or more blocks, and turn book pages one at a time. However, the fine motor skill required to tie shoes is usually not developed at this age. Full independence in dressing, using the bathroom, and eating typically occurs around 4 to 5 years of age. Therefore, the correct expectation for a 24-month-old child would be aligning two or more blocks. Choices A, B, and C are incorrect as they represent skills that are usually achieved at a later age.
5. When assessing Mr. Lee's eye condition, what general information should the nurse seek?
- A. Type of employment.
- B. Burning or itchy sensation in the eyes.
- C. Position of the eyelids.
- D. Existence of floaters.
Correct answer: A
Rationale: When assessing a patient's eye condition, the nurse should seek general information such as the type of employment, activities, allergies, medications, lenses, and protective devices used. This information helps in understanding potential exposures to irritants and risks related to activities. While the presence of burning or itchy sensation in the eyes, position of the eyelids, and existence of floaters are important aspects to assess during a focused eye examination, during the initial assessment, the type of employment is more relevant for understanding possible environmental factors affecting eye health.
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