NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A pregnant client is being educated by a nurse on nutrition and foods rich in folic acid. Which food item does the nurse inform the client contains the highest amount of folic acid?
- A. Pinto beans
- B. Lettuce
- C. Oranges
- D. Broccoli
Correct answer: A
Rationale: Pinto beans contain the highest amount of folic acid among the options provided, with 294 mcg per 1-cup serving. Oranges contain 44 mcg per 1-cup serving, lettuce contains 60 mcg per 1-cup serving, and broccoli contains 78 mcg per 1-cup serving. Therefore, pinto beans are the best choice for increasing folic acid intake during pregnancy. Choosing oranges, lettuce, or broccoli would not provide as much folic acid compared to pinto beans, making them less optimal choices for meeting folic acid requirements during pregnancy.
2. What is the primary theory that explains a family's concept of health and illness?
- A. Health Belief Model
- B. Education Factor
- C. Family Health Belief Model
- D. Family Dynamics Model
Correct answer: A
Rationale: The correct answer is the Health Belief Model. The Health Belief Model is a widely recognized theory that explains individuals' perceptions and behaviors related to health and illness. It considers factors such as perceived susceptibility, severity of health issues, benefits of action, and barriers to taking action. Choices B, C, and D are incorrect. Choice B, 'Education Factor,' is too general and does not specifically address a family's concept of health and illness. Choice C, 'Family Health Belief Model,' is a combination of terms and not a recognized theory. Choice D, 'Family Dynamics Model,' focuses on family interactions rather than explaining a family's concept of health and illness.
3. A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips in which location?
- A. Behind the knee
- B. Lateral to the extensor tendon of the big toe
- C. In the groove between the malleolus and the Achilles tendon
- D. Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines
Correct answer: B
Rationale: The correct location to palpate the dorsalis pedis pulse is lateral to and parallel with the extensor tendon of the big toe. Choices A, C, and D describe the locations for other pulses - popliteal, posterior tibial, and femoral artery respectively. The popliteal pulse is found behind the knee, the posterior tibial pulse is located in the groove between the malleolus and the Achilles tendon, and the femoral artery is situated below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines.
4. While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
- A. Ask the parents to allow the infant to lie on his stomach to promote muscle development.
- B. Notify the physician because a developmental or neurological evaluation is indicated.
- C. Document the findings as abnormal in the nurse's notes.
- D. Explain to the parents that their child is likely to have developmental delays.
Correct answer: B
Rationale: Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on his stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. The findings are abnormal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurological and other metabolic disorders. While some of these disorders might include developmental delays, stating this to the parents without a proper evaluation can cause unnecessary distress. The priority is to identify the cause of the head lag through a medical evaluation before discussing potential outcomes with the parents.
5. When a 25-year-old client complains of chest congestion and cough after previously presenting with cold symptoms, what data should the nurse collect?
- A. Data related to follow-up care
- B. A complete health database
- C. Data related to the respiratory system
- D. Data related to the treatment for the cold
Correct answer: C
Rationale: In this case, the nurse should collect data related to the respiratory system since the client is presenting with symptoms like chest congestion and cough, indicating a respiratory issue. Focusing on the respiratory system will help gather pertinent information to assess the current problem comprehensively. A complete health database involves a detailed health history and full physical examination, which is beyond the immediate scope of the presenting issue. Data related to follow-up care is premature as the primary focus should be on assessing the current respiratory symptoms. Data related to the treatment for the cold is not the priority at this stage, as understanding the underlying respiratory problem is crucial for appropriate intervention.
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