NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. You are caring for a 78-year-old woman who is wondering why she was diagnosed with glaucoma. Although she has several risk factors, which of these is not one of them?
- A. age
- B. blood pressure reading of 143/89
- C. Mexican-American heritage
- D. 20/80 vision
Correct answer: D
Rationale: Age over 60 and Mexican-American heritage are recognized as risk factors for glaucoma. Elevated blood pressure is also a risk factor due to its potential to cause optic nerve damage. While 20/80 vision indicates poor eyesight, it is not a direct causal factor for glaucoma. Glaucoma is mainly associated with factors like age, ethnicity, and certain medical conditions, rather than a specific visual acuity measurement. Therefore, 20/80 vision is not a risk factor for glaucoma, making it the correct answer. The other choices, such as age, Mexican-American heritage, and elevated blood pressure, are established risk factors for developing glaucoma, as they are associated with an increased likelihood of the condition.
2. Which of the following foods is a complete protein?
- A. corn
- B. eggs
- C. peanuts
- D. sunflower seeds
Correct answer: B
Rationale: The correct answer is 'eggs.' Eggs are considered a complete protein as they contain all nine essential amino acids required by the body. On the other hand, corn, peanuts, and sunflower seeds are incomplete proteins, meaning they lack one or more of the essential amino acids needed by the body for optimal health. Corn, peanuts, and sunflower seeds are plant-based proteins that are deficient in one or more essential amino acids, unlike eggs, which are a high-quality complete protein source.
3. A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client?
- A. Supine
- B. Standing
- C. Lithotomy
- D. Left lateral
Correct answer: D
Rationale: For a rectal examination in a female client, the nurse should assist the client into the left lateral position. This position allows easier access to the rectal area, facilitating the examination. The lithotomy position is used for examining the genitalia and rectum in females, not solely for a rectal examination. The standing position is not appropriate for a rectal examination as it does not provide the necessary access. The supine position would hinder the effectiveness of a rectal examination as it does not optimize access to the rectal area.
4. A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?
- A. Stethoscope
- B. Doppler transducer
- C. Fetoscope
- D. Pulse oximetry on the client and a fetoscope
Correct answer: B
Rationale: To assess the fetal heart rate of a client who is 14 weeks pregnant, the nurse should use a Doppler transducer. Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation, making it the most appropriate choice for this scenario. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds, so it is an incorrect choice in this context.
5. Around what age do children typically start to develop 'stranger anxiety'?
- A. 9 months
- B. 6 months
- C. 3 months
- D. 12 months
Correct answer: B
Rationale: The correct answer is '6 months.' At around this age, children typically start to develop 'stranger anxiety' as they become more aware of unfamiliar faces and may start showing signs of distress or anxiety around strangers. At 3 months, infants are still very young and unlikely to display stranger anxiety. While by 9 or 12 months, children have usually already developed some level of stranger anxiety, it typically starts around 6 months, making it the most appropriate answer in this context.
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