the nurse is assessing an 18 month old which of these statements made by the parent or caregiver would require follow up

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?

A. I'm worried that my child is not using two-word phrases yet.
B. My child has recently taken a few steps but does not seem stable when standing.
C. My child seems to have developed separation anxiety when I leave.
D. I'm letting my child use a spoon to eat.

Correct answer: B

Rationale: The correct answer is 'My child has recently taken a few steps but does not seem stable when standing.' By 18 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by this age, a physical therapy evaluation may be necessary. It is normal for an 18-month-old to start using a spoon to eat. However, the use of two-word phrases is not typically expected until 2 years of age. Separation anxiety is a common developmental phase that typically occurs between 6 and 18 months, so it does not require immediate follow-up. Therefore, the statement about the child not being stable when standing raises a red flag and necessitates further evaluation.

2. Why is Kleinman's Explanatory Model of Health and Illness significant?

A. it explains the health beliefs a family is likely to have.
B. it emphasizes the role of culture in shaping health explanations.
C. it discusses the significant role of popular and folk domains of influence.
D. it is structured based on education.

Correct answer: B

Rationale: Kleinman's Explanatory Model of Health and Illness is significant because it emphasizes the crucial role that popular and folk domains of influence play in shaping individuals' understanding of health and illness. Kleinman distinguishes between disease, which is the biomedical understanding of health problems, and illness, which is the individual's personal interpretation of their health condition. By focusing on the cultural factors that influence these domains of influence, Kleinman's model underscores the impact of cultural beliefs and practices on health perceptions. Choice A is incorrect because the model goes beyond just family health beliefs. Choice B is more precise as it emphasizes the broader influence of culture. Choice C highlights the correct significance of popular and folk domains of influence, making it the correct choice. Choice D is incorrect as the model's significance lies in cultural domains, not educational structure.

3. A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant performs which action?

A. Uses short sentences
B. Speaks at a normal rate and volume
C. Uses facial expressions or gestures
D. Overarticulates words

Correct answer: D

Rationale: The correct answer is 'Overarticulates words.' When communicating with a hearing-impaired client who may rely on lip-reading, it is essential to speak clearly at a normal rate and volume. Overarticulating words can distort lip movements, making it harder for the client to understand. Using short sentences helps in conveying information effectively, allowing the client time to process. While facial expressions and gestures provide additional visual cues that aid in communication, overarticulating words can be counterproductive in this scenario. Therefore, the nursing assistant should avoid overarticulating words to ensure clear and concise communication for the client.

4. A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. The nurse interprets the client's results in which way?

A. The client is legally blind.
B. The client has normal vision.
C. The client can read at a distance of 20 feet what a client with normal vision can read at 80 feet.
D. The client can read at a distance of 80 feet what a client with normal vision can read at 20 feet.

Correct answer: D

Rationale: When interpreting visual acuity testing results using the Snellen chart, the recorded numeric fraction represents the distance the client is standing from the chart and the distance a normal eye could read that particular line. A reading of 20/80 means that the client can read at 20 feet what a client with normal vision can read at 80 feet. This indicates visual impairment but does not meet the criteria for legal blindness, which is defined as best-corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20. Therefore, the correct interpretation is that the client can read at a distance of 80 feet what a client with normal vision can read at 20 feet. Choice A is incorrect because 20/80 does not meet the criteria for legal blindness. Choice B is incorrect as the client's vision is impaired. Choice C is incorrect because it reverses the interpretation of the fraction.

5. Why is Kleinman's Explanatory Model of Health and Illness significant?

A. it focuses on the health beliefs of a particular family.
B. it highlights the impact of culture on health explanations.
C. it discusses the significant role of popular and folk domains of influence.
D. it is based on an educational approach.

Correct answer: C

Rationale: Kleinman's Explanatory Model of Health and Illness is significant because it emphasizes the influence of popular and folk domains on health perceptions. Kleinman distinguishes between disease, representing the biomedical view, and illness, reflecting individual understanding. The model underscores that cultural factors shape the significance of popular and folk influences on health beliefs. Choice A is incorrect as the model focuses on broader cultural influences, not individual family beliefs. Choice B is incorrect as it oversimplifies the model's emphasis on various cultural aspects. Choice D is incorrect as the model's significance lies in its cultural framework rather than an educational base.