a nurse is preparing to assess a client for the presence of the tinel sign which action does the nurse take to elicit this sign

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?

A. Testing for the strength of each muscle joint
B. Percussing at the location of the median nerve
C. Checking for repetitive movements in the joints
D. Asking the client to flex the wrist 90 degrees while holding the hands back to back

Correct answer: B

Rationale: The Tinel sign is elicited by percussing at the location of the median nerve at the wrist. In carpal tunnel syndrome, this test can produce burning and tingling along the nerve's distribution. Choices A, C, and D are incorrect. Testing for the strength of each muscle joint and checking for repetitive movements in the joints involve different assessments unrelated to the Tinel sign. Asking the client to flex the wrist 90 degrees while holding the hands back to back is associated with the Phalen test, which is another evaluation for carpal tunnel syndrome.

2. Which of the following vaccines contains a live virus?

A. varicella
B. IPV
C. DTaP
D. hepatitis B

Correct answer: A

Rationale: The correct answer is varicella. Varicella vaccine contains a live, weakened form of the varicella-zoster virus. Choice B, IPV (inactivated poliovirus vaccine), is an inactivated vaccine, not a live virus vaccine. Choices C and D, DTaP (diphtheria, tetanus, and acellular pertussis vaccine) and hepatitis B vaccine, respectively, do not contain live viruses. Varicella is the only live virus vaccine among the options.

3. To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask a client providing subjective data?

A. Do you normally experience menstrual cramps with your periods?
B. Do you smoke cigarettes?
C. Are you currently dieting?
D. Do you engage in strenuous exercise, such as jogging?

Correct answer: B

Rationale: The correct question the nurse should ask to identify risk factors associated with the use of an oral contraceptive is whether the client smokes cigarettes. Oral contraceptives are associated with an increased risk of thromboembolic phenomena, particularly when combined with other risk factors like smoking and a history of thrombosis. Other risk factors include hypertension, cerebrovascular disease, coronary artery disease, and postoperative thrombosis risk. Choices A, C, and D are not directly related to the increased risks associated with oral contraceptive use. Menstrual cramps, dieting, and strenuous exercise are not significant risk factors for thromboembolic events.

4. An appraisal of self-care practices involves an assessment of:

A. all diagnostic tests.
B. home treatment practices, including nurse visits for the sick or disabled.
C. the family's capability to get health insurance.
D. caregiving needs and the potential for strain.

Correct answer: D

Rationale: An appraisal of self-care practices focuses on assessing caregiving needs and the potential for strain. This involves evaluating the support system in place for individuals requiring care, the level of strain experienced by caregivers, and the overall impact of caregiving responsibilities on both the caregiver and the care recipient. The other options presented do not directly relate to the assessment of self-care practices. Diagnostic tests, home treatment practices, and the family's capability to obtain health insurance are important aspects of healthcare but do not specifically pertain to the evaluation of self-care practices.

5. A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

A. Headache
B. Neck trauma
C. Sinus infection
D. Muscle spasms

Correct answer: B

Rationale: A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.