NCLEX Health Promotion and Maintenance

1. Ana, a pregnant mother comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic? a. Labor techniques b. Danger signs during pregnancy c. Signs and symptoms of pregnancy d. Tests to evaluate for high-risk pregnancy

1. B. No matter how far the client's pregnancy has progressed by the time of her first prenatal visit, the nurse should teach about danger signs during pregnancy so the client can identify and report them early, helping to avoid complications. The nurse should discuss other topics just before they're expected to occur.

16. Which of the following clients has the lowest risk of obesity and diabetes mellitus? a. A 45 year old Native American male b. A 23 year old Asian-American female c. A 35 year old Hispanic-American male d. A 40 year old African-American female

16. B. Asian Americans have the lowest risk of obesity and diabetes mellitus from the options provided. Native Americans, African Americans, and Hispanic Americans have a high risk of obesity and diabetes mellitus.

17. Nurse Ruby instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food items lowest in potassium is: a. Apples b. Carrots c. Spinach d. Avocado

17. A. A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg, spinach (3½ oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium.

10. According to Erikson's theory of development, chronic illness can interfere with which stage of development in an 11-year-old? a. Intimacy versus isolation b. Trust versus mistrust c. Industry versus inferiority d. Identity versus role confusion

10. C. According to Erikson, an 11-year-old is working through the stage of industry versus inferiority. Chronic illness may interfere with this stage of development in an 11-year-old child. Intimacy is the developmental task of a young adult. Trust is the developmental task to be achieved during infancy. Identity is the developmental task of adolescence.

11. Nurse Andrew should teach a client to administer oxytocin (Syntocinon) nasal spray while: a. sitting with her head vertical b. lying down with her head turned to the side c. sitting with her head tilted back d. lying down with her head tilted back

11. A. Oxytocin nasal spray should be administered while the client is sitting with her head in a vertical position. A nasal preparation must not be administered with the client lying down or the head tilted back because this could cause aspiration.

12. Where is the best place for the nurse to detect fetal heart sounds for a client in the first trimester of pregnancy? a. Above the symphysis pubis b. Below the symphysis pubis c. Above the umbilicus d. At the umbilicus

12. A. In the first trimester, fetal heart sounds are loudest in the area of maximum intensity, just above the client's symphysis pubis at the midline. Fetal heart sounds aren't heard as well in the other locations.

13. A client scheduled for a vasectomy asks nurse Erryne how soon after the procedure he can have sexual intercourse without using an alternative birth control method. How should the nurse respond? a. "You can safely have intercourse after 6 to 10 ejaculations." b. "You can safely have intercourse when your sperm count indicates sterilization." c. "You can safely have intercourse immediately after the procedure." d. "You can safely have intercourse as soon as discomfort from the procedure disappears."

13. B. After a vasectomy, sterilization isn't ensured until the client's sperm count measures zero. This usually requires 6 to 36 ejaculations. Having intercourse immediately after the procedure or as soon as discomfort disappears may lead to pregnancy.

14. Nurse Juliet is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy? a. Iron deficiency anemia b. Varicosities c. Nausea and vomiting d. Gestational diabetes

14. A. Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further.

15. Gina, now at 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action? a. Make an appointment because the client needs to be evaluated b. Explain that these are expected problems for the latter stages of pregnancy c. Arrange for the client to be admitted to the birth center for delivery d. Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume

15.B. The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. These signs aren't indicative of heart failure. The client doesn't need to be seen or admitted for delivery.

18. Nurse Jess is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food items does the nurse instruct the client to avoid? a. Peas b. Cauliflower c. Low-fat yogurt d. Processed oat cereals

18. D. The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium.

19. Michael, a 21 year old adult has a cholesterol blood test done at a screening clinic sponsored by s local health club. The nurse volunteering at the screening teaches the client that diet and exercise should be used as health measures to keep the total cholesterol level below: a. 80 mg/dL b. 200 mg/dL c. 250 mg/dL d. 300 mg/dL

19. B. The nurse should counsel the client to keep the total cholesterol level under 200 mg/dL. This will aid in the prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life.

2. When developing a plan of care for a child, nurse Josefina identifies which eriksonian stage as corresponding to Freud's oral stage of psychosexual development? a. Initiative versus guilt b. Autonomy versus shame and doubt c. Trust versus mistrust d. Industry versus inferiority

2. C. Freud defined the first 2 years of life as the oral stage and suggested that the mouth is the primary source of satisfaction for the developing child. Erikson posited that infancy (from birth to age 12 months) is the stage of trust versus mistrust, during which the infant learns to deal with the environment through the emergence of trustfulness or mistrust. Initiative versus guilt corresponds to Freud's phallic stage. Autonomy versus shame and doubt corresponds to Freud's anal/sensory stage. Industry versus inferiority corresponds to Freud's latency period.

20. A female client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. Based on this results, nurse Perry plans to teach the client about the need to: a. Avoid infection b. Take in adequate fluids c. Prevent and recognize hypoglycemia d. Prevent and recognize hyperglycemia

20. D. In the test result for glycosylated hemoglobin A1c, 7% or less indicates good control, 7% to 8% indicates fair control, and 8% or higher indicates poor control. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

21. Nurse Irene is conducting a dietary assessment on a client who is on a vegan diet. She plans to provide dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet? a. Vitamin A b. Vitamin B12 c. Vitamin C d. Vitamin E

21. B. Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet.

22. Nurse Maureen is planning to teach a client with mal-absorption syndrome about the necessity of following a low- fat diet. She develops a list of high-fat foods to avoid and includes which food items on the list? a. Oranges b. Broccoli c. Cream cheese d. Broiled haddock

22. C. Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Fish is also naturally lower in fat. Cream cheese is a high-fat food.

23. A male client is recovering from abdominal surgery and has a large abdominal wound. Nurse Katty encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing? a. Milk b. Oranges c. Bananas d. Chicken

23. B. Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.

24. Nurse Jamie is developing a list of home care instructions for a client being discharged after a laparoscopic cholecytectomy. Which of the following instructions would be least appropriate to include in the postoperative discharge plan of care? a. Wound care b. Follow-up care c. Activity restrictions d. Deep-breathing exercise

24. D. The type of planning and instruction required varies with each individual and the type of surgery. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Deep-breathing exercises are taught in the preoperative period.

25. Ashley, a pregnant mother tells the clinic nurse that she wants to know the sex of the baby as soon as it can determined. The nurse knows that the client should be able to find out at 12 weeks' gestation because by the end of the twelfth week: a. The sex of the baby can be determined by the appearance of the external genitalia b. The sex of the baby can be determined because the external genitalia begin to differentiate. c. The sex of the baby can be determined because the testes are descended into the scrotal sac. d. The sex of the baby can be determined because the internal differences in males and females become apparent.

25. A. By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Option B occurs at the end of the ninth week.

3. At a public health fair, nurse Karen teaches a group of women about breast cancer awareness. Possible signs of breast cancer include: a. Fever b. breast changes during menstruation c. nipple discharge and a breast nodule d. fever and erythema of the breast

3. C. Nipple discharge, breast nodules, nipple retraction, and lymphadenopathy may be signs of breast cancer and should be reported. Mammary duct ectasia may cause fever, nipple discharge, breast nodules, erythema of the breast, and itching. Breast changes during menstruation are normal; for this reason, women should examine their breasts 4 to 7 days after the menstrual period ends, when the breasts are least congested. Fever and erythema of the breast may indicate a breast abscess.

4. A female newborn born by elective cesarean section to a 25-year-old mother weighs 3,265 g (7 lb, 3 oz). Nurse Agatha places the newborn under the warmer unit. In addition to routine assessments, the nurse should closely monitor this newborn for which of the following? a. Temperature instability due to type of birth b. Respiratory distress due to lack of contractions c. Signs of acrocyanosis d. Unstable blood sugars

4. B. The squeezing action of the contractions during labor enhances fetal lung maturity. Infants who aren't subjected to contractions are at an increased risk for developing respiratory distress. The type of birth has nothing to do with temperature or glucose stability, and acrocyanosis is a normal finding.

5. Nurse Ellen is aware that the following factors can cause hepatitis A? a. Contact with infected blood b. Blood transfusions with infected blood c. Eating contaminated shellfish d. Sexual contact with an infected person

5. C. Hepatitis A can be caused by consuming contaminated water, milk, or food — especially shellfish from contaminated water. Hepatitis B is caused by blood and sexual contact with an infected person. Hepatitis C is usually caused by contact with infected blood, including receiving blood transfusions.

6. Which findings would be considered positive signs of pregnancy? a. Fatigue and skin changes b. Quickening and breast enlargement c. Fetal heartbeat and fetal movement on palpation d. Abdominal enlargement and Braxton Hicks contractions

6. C. Fetal heartbeat and fetal movement on palpation are considered positive signs of pregnancy because they can't be caused by any other condition

7. A male client undergoes a purified protein derivative (PPD) test for tuberculosis. After injecting PPD, nurse Remy should plan to read the test results after waiting: a. 12 hours b. 24 hours c. 36 hours d. 48 hours

7. D. Skin tests for tuberculosis require a delay in reading the reaction to allow sufficient time for antibodies to respond to the injected antigen. The nurse should read the client's PPD test for size of induration 48 hours after injection. Reading it earlier may lead to a false-negative result.

8. Which of the following would nurse Jacob expect to see in an elderly client's skin? a. Increased elasticity b. Increased sweat production c. Slowed healing d. Increased nail growth

8. C. When a person ages, the skin heals more slowly, loses elasticity, develops wrinkles, and undergoes pigmentation changes. Hair loses pigmentation and hair and nails grow more slowly. Sweat gland production diminishes.

9. Nurse Jeng is performing a psychosocial assessment on an adolescent, age 14. Which emotional response is typical during early adolescence? a. Frequent anger b. Cooperativeness c. Moodiness d. Combativeness

9. C. During early adolescence, a child may become moody. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.