a nurse assisting with data collection plans to perform the romberg test after describing the test to the client the nurse tells the client that it wi
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

Correct answer: B

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

2. Mr. H. is upset about being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:

Correct answer: D

Rationale: Confidentiality is the maintenance of privacy of information, which is not directly related to the issue Mr. H. is facing. The question indicates that Mr. H. is concerned about the cost of staying in the hospital, which pertains more to financial aspects and the right to examine and question the bill. The right to a reasonable response to requests and the right to refuse treatment are also crucial patient rights that Mr. H. may demand in his current situation. Therefore, the correct answer is the right to confidentiality, as it is not specifically relevant to the scenario presented.

3. Which of the following substances need to be assessed when completing a family health assessment?

Correct answer: D

Rationale: When completing a family health assessment, it is essential to assess all substances consumed by family members, including coffee, tea, cola, cocoa, alcohol, tobacco, illegal substances, and medicines prescribed by a physician. Understanding the complete picture of substance use within the family is crucial for identifying potential health risks and providing appropriate care. Choice D, 'all of the above,' is the correct answer as it encompasses the comprehensive assessment of all substances. Choices A, B, and C are incorrect as they only present partial aspects of substance assessment and do not cover the full range of substances that should be evaluated in a family health assessment.

4. During a voice test, how should the nurse provide words for the client to repeat?

Correct answer: B

Rationale: During a voice test, the nurse should whisper words from the client's side at a distance of 1 to 2 feet from the ear being tested. This distance helps prevent transmission around the head and ensures accurate testing of one ear at a time. By standing close to the client and whispering, the nurse prevents lip-reading and compensatory actions by the client. The client with normal hearing should be able to repeat each word correctly. Choices A, C, and D are incorrect. Choice A is wrong as the voice should be whispered, not spoken in a soft tone. Choice C is inaccurate because a distance of 10 feet is too far for precise testing. Choice D is incorrect as whispering from a distance of 20 feet would not effectively test the client's hearing.

5. Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus?

Correct answer: C

Rationale: The correct answer is midway between the symphysis pubis and the umbilicus. Immediately after delivery, the uterus is about the size of a large grapefruit or softball. The fundus can be palpated at this location but then rises to a level just above the umbilicus before sinking to the level of the umbilicus, where it remains for about 24 hours. After 24 hours, the fundus starts descending gradually. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Choices A and B are incorrect as the fundus is not initially at the level of the umbilicus or 2 centimeters above it. Choice D is also incorrect as the fundus does not remain in the pelvic cavity immediately after delivery.

Similar Questions

A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?
During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?
The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?
Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?
Which of the following vaccines is not part of the regular schedule of immunizations for children?

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