NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. During a routine health screening, the nurse should talk to the parents of a 1-year-old child about which of the following?
- A. the potential hazards of accidents
- B. appropriate nutrition now that the child has been weaned from breastfeeding
- C. toilet training
- D. how to prevent accidents in the house
Correct answer: A
Rationale: During a routine health screening for a 1-year-old child, discussing the potential hazards of accidents is crucial. Accidents are the primary source of injury in children and can be life-threatening. Addressing appropriate nutrition now that the child has been weaned from breastfeeding should have already been discussed. Toilet training is important but is typically addressed at a later age as one year is too early for this milestone. While preventing accidents in the house is important, focusing on the potential hazards of accidents in general is more comprehensive and critical for the child's safety.
2. According to Erik Erikson's developmental theory, which choice is a developmental task of the middle adult?
- A. Redefining self-perception and capacity for intimacy
- B. Making decisions concerning career, marriage, and parenthood
- C. Providing guidance during interactions with his children
- D. Verbalizing readiness to assume parental responsibilities
Correct answer: C
Rationale: According to Erikson's developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Providing guidance during interactions with his children aligns with this developmental task. Choices A, B, and D are not specific to the middle adult stage as they are tasks associated with young adults. Redefining self-perception and capacity for intimacy, making decisions concerning career, marriage, and parenthood, and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult according to Erikson's theory.
3. The LPN is caring for a 9-month-old infant. Which of these behaviors exhibited by the child warrants further investigation?
- A. She prefers crawling over walking and makes no attempt to walk.
- B. She seems distressed by new adults.
- C. She does not respond to her own name.
- D. She only babbles "mama"? and "dada."?
Correct answer: C
Rationale: The correct answer is that the child does not respond to her own name. By 9 months, children should be babbling simple words, crawling, and responding to their name. Not responding to one's name can be an early indicator of a potential developmental delay, warranting further investigation. Preferring crawling over walking, being distressed by new adults, and babbling 'mama' and 'dada' are typical behaviors for a 9-month-old and do not necessarily require immediate concern.
4. 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.
5. 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.
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