a nurse is performing a throat assessment on an assigned client on asking the client to stick his tongue out the nurse notes that it protrudes in the
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NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. During a throat assessment, a healthcare provider asks a client to stick out their tongue and notices it protrudes in the midline. Which cranial nerve is being tested?

Correct answer: D

Rationale: The correct answer is cranial nerve XII (hypoglossal nerve). When testing cranial nerve XII, the healthcare provider inspects the symmetry and movement of the tongue. The tongue should protrude in the midline when the client sticks it out. Cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve) are tested by depressing the tongue with a blade to observe pharyngeal movement and gag reflex. Cranial nerve V (trigeminal nerve) is responsible for testing the muscles of mastication, not tongue protrusion.

2. A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding?

Correct answer: C

Rationale: In later adulthood, age-related findings include trophic changes associated with arterial insufficiency, such as thin, shiny skin; thin, ridged toenails; and loss of hair on the lower legs. These changes occur normally with aging. Thick skin on the lower legs would not be an expected age-related finding as it typically indicates chronic venous insufficiency. A bounding dorsalis pedis pulse is not typical in later adulthood and may indicate arterial insufficiency, which is not an age-related finding.

3. A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which topic does the nurse ask the client about first?

Correct answer: B

Rationale: The nurse should begin by asking the client about her menstrual history as it is usually nonthreatening. This information can provide insights into the client's reproductive health and any irregularities. Menstrual history is a common starting point for gynecological assessments and can help in understanding the client's overall health status. Asking about sexual history may be more sensitive and personal, not always appropriate to start with. Obstetrical history pertains to pregnancies and may not be relevant if the client has not been pregnant. Inquiring about the presence of vaginal drainage is important but is usually addressed after gathering more general information about the client's health.

4. People who live in poverty are most likely to obtain health care from:

Correct answer: D

Rationale: Individuals living in poverty often face barriers to accessing regular healthcare services, leading them to utilize Emergency Departments or urgent care centers as their primary source of healthcare. These facilities provide immediate care without the need for appointments or insurance, making them more accessible to those in poverty. While primary care physicians and neighborhood clinics are essential for preventive care, individuals in poverty may have difficulty accessing these services due to financial constraints or lack of insurance. Specialists typically require referrals and may not be easily accessible to individuals without stable healthcare coverage. Therefore, Emergency Departments or urgent care centers are the most likely healthcare option for people living in poverty.

5. During the health screening of an adolescent, which finding by the nurse requires further teaching?

Correct answer: B

Rationale: The correct answer is 'The client states she is currently taking birth control pills.' This finding requires further teaching because being on birth control pills does not protect against sexually transmitted diseases (STDs), and the adolescent should be educated on the importance of using barrier methods (e.g., condoms) for STD prevention. Choices A, C, and D are not concerning. Choice A is a normal developmental milestone in adolescence. Choice C could indicate a positive lifestyle change, and choice D is a common complaint during this stage of development.

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