a nurse is assisting with data collection of a client with suspected cholecystitis which finding does the nurse expect to note if cholecystitis is pre
Logo

Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. 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?

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.

2. When assisting the physician in performing transillumination of a client's scrotum, how should the nurse prepare for this procedure?

Correct answer: A

Rationale: When preparing for transillumination of the scrotum, the nurse should obtain a flashlight and darken the room. This is done to allow the strong flashlight to be shined from behind the scrotal contents. Normal scrotal contents do not appear on transillumination. Instructing the client to drink fluids or to take deep breaths and bear down is not part of the preparation for this procedure. Additionally, it is not necessary to inform the client that the procedure is uncomfortable as transillumination is a painless procedure.

3. The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?

Correct answer: D

Rationale:

4. A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?

Correct answer: D

Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.

5. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?

Correct answer: C

Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.

Similar Questions

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:
A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action?
The LPN on shift notices a client coming into the clinic with bruises on his arm. The client seems very afraid and doesn't speak much, which concerns the nurse because these are signs of physical abuse. The nurse should ____.
Which of the following substances need to be assessed when completing a family health assessment?
When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses