NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1.
- A. Notify the registered nurse of the findings.
- B. Document the findings in the client's medical record.
- C. Recheck the vital signs in 1 hour.
- D. Continue collecting subjective and objective data.
Correct answer: A
Rationale:
2. What is the most appropriate initial action for a newborn infant with low blood glucose?
- A. Ask the registered nurse to draw another blood sample in 2 hours and repeat the test
- B. Contact the healthcare provider
- C. Contact the registered nurse
- D. Document the results in the newborn's medical record
Correct answer: C
Rationale: The blood glucose level for a newborn infant should remain greater than 40 mg/dL to prevent permanent brain damage. When dealing with low blood glucose in a newborn, the most appropriate initial action is to contact the registered nurse. The nurse will obtain prescriptions regarding feeding the infant with low blood glucose and follow agency policies on feeding infants in such conditions. It is common practice to feed the infant if the glucose level is 40 mg/dL or less. Asking the registered nurse to draw another blood sample in 2 hours and repeating the test is not the most appropriate immediate action, as timely intervention is crucial in this situation. Contacting the healthcare provider may cause unnecessary delays since the registered nurse is usually the first point of contact for immediate actions in this scenario. Documenting the results in the newborn's medical record is essential, but it is not the initial step in managing low blood glucose in a newborn.
3. All of the following factors, when identified in the history of a family, are correlated with poverty except:
- A. high infant mortality rate
- B. frequent use of Emergency Departments
- C. consultation with folk healers
- D. low incidence of dental problems
Correct answer: D
Rationale: The correct answer is 'low incidence of dental problems.' Dental problems are prevalent in families living in poverty due to the lack of preventive care and access to dental services. High infant mortality rate is closely correlated with poverty as it reflects various social determinants of health. Families in poverty may resort to frequent use of Emergency Departments due to limited access to primary care. Consulting with folk healers is also common among families in poverty as they might seek alternative and more accessible healthcare options. However, a low incidence of dental problems is less likely in families experiencing poverty.
4. A home health care nurse is visiting a male African American client who was recently discharged from the hospital. Which family member does the nurse ensure is present when teaching the client about his prescribed medications?
- A. The client's grandson
- B. The client's mother
- C. The client's father
- D. The client's son
Correct answer: B
Rationale: In the African American family structure, the woman, especially the mother, often plays a central role in healthcare decisions and maintaining family health. It is essential for the nurse to involve the client's mother in teaching him about his prescribed medications as she may be responsible for his care and treatment decisions. While other family members may also be involved, the African American family is often matrifocal, emphasizing the importance of the mother's role. Therefore, it is crucial for the nurse to ensure the client's mother is present during medication teaching. Choices A, C, and D are incorrect as they do not align with the traditional African American family structure and the role of women in healthcare decisions.
5. What causes an older female client's hair to turn gray?
- A. ''A loss of melanin occurs in the normal aging process.''
- B. ''The number of sweat glands and blood vessels decreases in the normal aging process.''
- C. ''The skin on the scalp becomes thin, causing moisture to escape.''
- D. ''It is caused by hereditary factors.''
Correct answer: A
Rationale: The correct answer is 'A loss of melanin occurs in the normal aging process.' Graying hair in older adults is primarily due to a decrease in the number of melanocytes responsible for providing pigment and hair color. This reduction in melanin production leads to gray hair. The other choices are incorrect. While it is true that the skin becomes thinner with aging and the number of sweat glands and blood vessels decreases, these changes are not directly related to graying hair. Additionally, hereditary factors can influence when graying starts, but they do not cause the graying of hair itself.
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