NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. Which of the following statements is correct about Maslow's hierarchy of needs?
- A. There are psychosocial interventions that may be applicable to all of the levels.
- B. There are physical interventions that may be applicable to all of the levels.
- C. Two of the levels may require physical intervention while four of the levels may require psychosocial intervention.
- D. Four of the levels may require physical intervention, while two of the levels may require psychosocial intervention.
Correct answer: C
Rationale: The correct statement about Maslow's hierarchy of needs is that two of the levels may require physical intervention while four of the levels may require psychosocial intervention. Maslow's theory suggests that physiological and safety needs are more basic and may require physical interventions, while social, esteem, and self-actualization needs are more psychosocial. Choices A and B are incorrect as they wrongly suggest that all levels may require only one type of intervention. Choice D is incorrect because it inaccurately represents the balance of physical and psychosocial interventions in Maslow's hierarchy of needs.
2. How often should a 5-year-old child undergo a dental examination?
- A. Every 6 months
- B. Whenever a new primary tooth erupts
- C. Once a year
- D. Every 3 months
Correct answer: A
Rationale: For a 5-year-old child, dental examinations should be conducted every 6 months. This frequency allows for early detection of dental issues and promotes good oral health. Choices B, C, and D are incorrect because waiting for a new primary tooth to erupt, having an examination once a year, or every 3 months are not the recommended intervals for dental check-ups in this age group. It is essential to adhere to the standard guideline of every 6 months to ensure regular monitoring and preventive care for the child's dental health.
3. A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?
- A. Notify the healthcare provider of the finding.
- B. Document the findings.
- C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
- D. Wait 15 minutes and then recheck the FHR.
Correct answer: B
Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.
4. A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the healthcare provider expect to administer in addition to the scheduled vaccines?
- A. pneumococcal vaccine
- B. hepatitis A vaccine
- C. Lyme disease vaccine
- D. typhoid vaccine
Correct answer: A
Rationale: The correct answer is the pneumococcal vaccine. Children with HIV are at increased risk of pneumococcal infections, so the pneumococcal vaccine is recommended as a supplemental vaccine for them. The hepatitis A vaccine is not routinely given to HIV-positive children unless they have other risk factors for hepatitis A. Lyme disease vaccine is for individuals at risk for Lyme disease, not routinely recommended for a 2-year-old. Typhoid vaccine is typically given to individuals traveling to endemic areas or working in settings with potential exposure to Salmonella typhi, not a routine vaccine for a 2-year-old with HIV.
5. When assessing the carotid artery of a client with cardiovascular disease, what action should a nurse perform?
- A. Palpating the carotid artery in the upper third of the neck
- B. Palpating both arteries simultaneously to compare amplitude
- C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits
- D. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery
Correct answer: C
Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.
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