NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. When working with multicultural populations, the nurse should consider all of the following when planning care for a client with an altered sexuality pattern except:
- A. some Hispanic and Native-American cultures are very open when discussing sexuality.
- B. some cultures view the postpartum period as a state of impurity.
- C. some women in the African-American culture view childbearing as a validation of their femaleness.
- D. some Native-American women believe monthly menstruation maintains physical well-being and harmony.
Correct answer: A
Rationale: When working with multicultural populations, it is essential to understand cultural variations in beliefs and practices related to sexuality. While it is true that some cultures view the postpartum period as a state of impurity and that some women in the African-American culture view childbearing as a validation of their femaleness, the statement 'some Hispanic and Native-American cultures are very open when discussing sexuality' is incorrect. In reality, many cultures, including Hispanic and Native-American cultures, are sometimes hesitant to discuss sexuality. For example, some Navajos, Hispanics, and Orthodox Jews may consider the postpartum period as impure, leading to seclusion of women until the end of bleeding, marked by a ritual bath. Additionally, many Native-American women believe in the importance of monthly menstruation for physical well-being and harmony. Therefore, the statement about Hispanic and Native-American cultures being very open about discussing sexuality is not accurate in the context of working with multicultural populations.
2. According to Erikson, which developmental task is a toddler confronting when they develop 'a will of his own' and 'acts as if he can control others'?
- A. Trust versus mistrust
- B. Autonomy versus doubt and shame
- C. Initiative versus guilt
- D. Industry versus inferiority
Correct answer: B
Rationale: According to Erikson, the correct developmental task for a toddler who has developed 'a will of his own' and 'acts as if he can control others' is Autonomy versus doubt and shame. Toddlers at this stage are asserting their wills and realizing they can control others, which is part of developing autonomy. However, they may also experience doubt and shame if their assertiveness is met with disapproval. Trust versus mistrust is the developmental task of the infant, where the main focus is on developing trust in the caregiver. Initiative versus guilt is the developmental task of the preschool-age child, emphasizing the balance between taking initiative and feeling guilty. Industry versus inferiority is the developmental task of the school-age child, focusing on competence and self-esteem.
3. A nurse assisting with data collection notes that the client's skin is very dry. The nurse documents this finding using which term?
- A. Xerosis
- B. Pruritus
- C. Seborrhea
- D. Actinic keratoses
Correct answer: A
Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Xerosis is the correct term for very dry skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin, but it does not specifically refer to dry skin. Seborrhea is a skin condition characterized by overproduction of sebum, leading to excessive oiliness or dry scales, not necessarily indicating very dry skin. Actinic keratoses are sun-related skin lesions that are premalignant and not associated with dry skin.
4. A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?
- A. Homan sign
- B. Murphy sign
- C. Blumberg sign
- D. McBurney sign
Correct answer: B
Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.
5. When performing the confrontation test to assess peripheral vision, what action should the nurse take?
- A. Asks the client to identify a small object brought into the visual field
- B. Has the client cover one eye while the nurse covers one eye and slowly advances a target midline between them
- C. Covers one eye, while the client covers the opposite eye, and brings a small object into the visual field
- D. Positions at eye level with the client, covers one eye, and has the client cover the opposite eye, then brings a small object into the visual field
Correct answer: D
Rationale: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits. Choices A, B, and C are incorrect. Choice A pertains to testing color vision, which is not part of the confrontation test. Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test. Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.
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