NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?
- A. Sex role identification begins in infancy.
- B. Sex role identification begins in the preschool years.
- C. Sex role identification begins during the school-age years.
- D. Sex role identification begins during early adolescence.
Correct answer: A
Rationale: Sex role identification begins during infancy as infants can identify body parts by the end of the first year. Preschoolers often engage in masturbation and sex play. School-age children continue to develop awareness of their sexual identity, including behaviors like hugging and kissing. Early adolescence sees further development influenced by sexual maturation and experimentation with sex roles. Therefore, the correct statement is that sex role identification begins in infancy. Choices B, C, and D are incorrect as they misrepresent the timeline of the development of sex role identification in children.
2. The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible
- B. taking care of the whole person"?body, mind, spirit, heart, and soul
- C. no interventions are needed because the client is near death
- D. supporting the needs of the family and client
Correct answer: C
Rationale: The goals of palliative care include choices A, B, and D. Choice C, 'no interventions are needed because the client is near death,' is not part of palliative care. Palliative care involves giving clients with life-threatening illnesses the best quality of life possible, taking care of the whole person"?body, mind, spirit, heart, and soul, and supporting the needs of the family and client. Interventions are crucial in palliative care to ensure the comfort and well-being of the client until the end of life. Therefore, the correct answer is that no interventions are needed because the client is near death.
3. A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse makes which determination?
- A. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth
- B. The results are negative.
- C. The results indicate that the mother does not have hepatitis B
- D. The client needs to receive the hepatitis B series of vaccines.
Correct answer: A
Rationale: A hepatitis B screen is performed to identify antigens in maternal blood. If antigens are present, it indicates that the mother is a carrier, and the newborn will need to receive hepatitis immune globulin and vaccine soon after birth to prevent transmission. Therefore, choice A is correct. Choices B and C are incorrect because the presence of antigens indicates a positive result, not a negative one or the absence of hepatitis B in the mother. Choice D is incorrect as it suggests the client needs to receive the hepatitis B series of vaccines, which is not the immediate action required when antigens are found in the maternal blood.
4. Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus?
- A. At the level of the umbilicus
- B. Two centimeters above the umbilicus
- C. Midway between the symphysis pubis and umbilicus
- D. In the pelvic cavity
Correct answer: C
Rationale: The correct answer is midway between the symphysis pubis and the umbilicus. Immediately after delivery, the uterus is about the size of a large grapefruit or softball. The fundus can be palpated at this location but then rises to a level just above the umbilicus before sinking to the level of the umbilicus, where it remains for about 24 hours. After 24 hours, the fundus starts descending gradually. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Choices A and B are incorrect as the fundus is not initially at the level of the umbilicus or 2 centimeters above it. Choice D is also incorrect as the fundus does not remain in the pelvic cavity immediately after delivery.
5. At what age are yearly mammograms recommended to start?
- A. Yearly mammograms are recommended starting at age 25.
- B. Yearly mammograms are recommended starting at age 40.
- C. Yearly mammograms are not necessary unless there is a family history of breast cancer.
- D. Yearly mammograms are recommended starting at age 20 and continuing until menopause begins.
Correct answer: B
Rationale: The correct answer is B. The American Cancer Society recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Clinical breast examination should be done about every 3 years for women in their 20s and 30s and every year for women age 40 and older. Women should know how their breasts normally look and feel and report any breast change promptly to the healthcare provider. Breast self-examination should be done monthly starting when a woman is in her 20s. Choice A is incorrect as mammograms are not recommended to start at age 25. Choice C is incorrect as yearly mammograms are still recommended even without a family history of breast cancer. Choice D is incorrect as the recommended age for starting yearly mammograms is 40, not 20.
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