NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. During a voice test, how should the nurse provide words for the client to repeat?
- A. Spoken in a soft tone of voice by the nurse about 5 feet in front of the client
- B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested
- C. Spoken by the nurse from the client's side in a normal tone of voice about 10 feet from the ear being tested
- D. Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client
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.
2. A teenager is preparing to care for a hospitalized teenage girl who is in skeletal traction. The teenager assists with planning care knowing that which is the most likely primary concern of the teenage girl?
- A. Keeping up with schoolwork
- B. Body image
- C. Obtaining adequate rest and sleep
- D. Obtaining adequate nutrition
Correct answer: B
Rationale: The correct answer is 'Body image.' Adolescents, especially teenage girls, are often preoccupied with their appearance and body image. When facing a situation like being in skeletal traction, which can affect their physical appearance, body image becomes a primary concern. Concerns about body image can significantly impact their self-esteem and emotional well-being. Choice A, 'Keeping up with schoolwork,' is important but typically not the primary concern in this context. Choices C and D, 'Obtaining adequate rest and sleep' and 'Obtaining adequate nutrition,' are crucial for overall health but are secondary to the significant impact that body image concerns can have on a teenage girl in this situation.
3. While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?
- A. Document the finding
- B. Palpate the area for a mass
- C. Notify the healthcare provider
- D. Percuss the abdomen to check for tympany
Correct answer: C
Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.
4. What is the primary force in sex education in a child's life?
- A. school nurse
- B. peers
- C. parents
- D. media
Correct answer: C
Rationale: Parents are the primary force in sex education in a child's life. Parents play a central role in shaping a child's understanding of sex from an early age. They provide continuous guidance, values, and information about sex and relationships. While the school nurse is involved in formal sex education and counseling within the school setting, parents have the most direct and significant impact on a child's sex education. Peers become more influential during adolescence, but their information may not always be accurate or appropriate. The media also exert significant influence on children's perceptions of sex through various forms of entertainment like movies, TV shows, and video games, but parents remain the primary educators on this subject.
5. An allergic reaction is classified as what type of pharmacological effect?
- A. a therapeutic effect
- B. a side effect
- C. an adverse effect
- D. an incompatibility
Correct answer: C
Rationale: An allergic reaction is classified as an adverse effect because it is an unintended response to a medication that requires treatment. A side effect is an undesired but somewhat expected reaction to a drug that does not necessarily need intervention. Incompatibility refers to an unsuitable combination of substances that leads to an adverse effect. A therapeutic effect is the desired and intended outcome of a medication.
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