NCLEX Health Promotion Review
1. Which of the following statements, if made by a male cancer patient with hair loss secondary to chemotherapy, indicates the goal for new coping patterns is being met? a. I think I'll get some new barrettes for my hair b. I washed my wig today c. I asked my mom to bring my shampoo d. I'm thinking about changing my hair color
1. B. One of the two indicators that the goal for implementing new coping patterns has been met is a willingness and ability to resume self-care responsibilities. Statement B shows that the client is taking care of their wig, a new self-care responsibility.
10. Which of the following clinical manifestations should nurse Lea document as a positive sign of pregnancy? a. Amenorrhea b. uterine soufflé c. positive pregnancy test d. fetal heartbeat
10. D. Fetal heartbeat can be detected with Doppler as early as 10-12 weeks of pregnancy and is considered a positive or diagnostic sign of pregnancy. Amennorrhea, the absence of menses, is considered a presumptive sign of pregnancy. It is a more helpful sign when more than one cycle has been missed. Uterine soufflé, the sound heard on auscultation over the uterus that is caused by blood flow through the placenta, can also be caused by other conditions such as ovarian tumors or uterine myomas. It is considered a probable sign of pregnancy. A positive pregnancy test is based on the detection of Human Chorionic Gonadotropin. It is present during pregnancy, but there are other conditions that can cause it to be elevated so it is considered a probable sign of pregnancy.
11. A woman who is 20 weeks pregnant has been taught about fetal development. Which of the following statements, if made by her, indicate that she has correctly understood what has been taught? a. My baby is able to breathe now b. My baby can open his eyes c. My baby's about 7 ½ inches long d. My baby's starting to grow fingernails
11. C. By 20 weeks gestation the fetus is approximately 10 cm long or 7 ½ inches. Fetal lungs do not begin the movements of respiration until 24 weeks. Because oxygen is provided through the placenta, the function of the lungs for breathing does not occur until birth. The fetus can open its eyes at 28 weeks gestation. Fingernails begin to grow at 10 weeks gestation but are not complete until 38 weeks.
12. Which of these self-care measures should nurse Mickey suggest first for a woman in her third trimester of pregnancy who is experiencing ankle edema, leg cramps, and faintness? a. Practice frequent dorsi-flexion of the feet b. Wear support hose c. Avoid standing for long periods of time d. Elevate legs when sitting
12. A. The first self-care measure to suggest is to practice frequent dorsi-flexion of the feet. If this is done, it would provide relief for two of the three symptoms the woman is experiencing: ankle edema and leg cramps
13. The parents of a newborn have been given instructions about which toys are appropriate for their infant. Which of these statements, if made by the parents, would indicate that they correctly understood the instructions? a. It will be so much fun picking out a jack-in-the-box b. I bet he'd enjoy one of those animals that squeaks when you squeeze it c. Let's get him one of those teething rings that we can put in the freezer d. We should hunt for a mirror that won't break
13. D. Newborns and young infants enjoy looking at themselves in the mirror. The human face is pleasing to them. Nurses must instruct parents to buy unbreakable mirrors to prevent injury. A jack-in-the-box may be fun for the parents, but a newborn does not have the capacity to turn the handle and make it work. This is too advanced a toy for a newborn
14. Which of these strategies would the nurse suggest the parents add to their activities to promote tactile stimulation for an 11-month-old? a. Give the infant finger foods of different textures b. Provide soft squeeze toys of various textures c. Allow the infant to play nude on a soft, furry rug d. Comb the infant's hair with a soft brush
14. A. Finger foods are just now being introduced into the infant's diet. Providing finger foods with different textures is a natural way to promote tactile stimulation. All of the remaining answers will provide tactile stimulation, but the question wants to know what to add.
15. Which nursing measure should assume priority in performing a physical examination on an 8-month-old infant who is sitting contently on his mother's lap chewing on a toy? a. Take the toy away so that the mouth can be observed b. Begin a systematic physical exam, beginning at the head and moving toward the feet c. Remove all the infant's clothing so a thorough exam can be performed d. Auscultate the heart and lungs and then proceed with the rest of the exam
15. D. The order of the physical exam should be adjusted to accommodate the developmental age of the child and the response of the child to being examined. Since the child is quiet and distracted with the chew toy, the nurse should be able to get a good listen to the heart and lungs without the child crying or squirming.
16. When a child demonstrates a positive Babinski sign, which age child would be most important for the nurse to follow-up? a. 4 months b. 8 months c. 12 months d. 16 months
16. D. The Babinski sign is positive in children 12 months of age and younger. A 16-month-old with a positive Babinski would be cause for concern and require further evaluation. A positive Babinski is normal for a 4, 8, and 12-month-old child and not a cause for follow-up.
17. Which of these self-care measures would the nurse include when teaching a pregnant woman about exercise? a. Check your pulse while exercising and slow your pace if your pulse rate reaches 160 b. You may exercise to the point of fatigue but should avoid exhaustion c. Avoid exercising in the supine position after the first trimester d. After exercise relax in the hot tub or sauna for 10 minutes
17. C. After the first trimester the pregnant woman should avoid exercising in the supping position. This is associated with decreased cardiac output. As a general rule, pregnant women should not engage in exercise that causes their heart rate to exceed a maximum of 140 beats per minute. Per the American College of Obstetricians and Gynecologists, pregnant women should not exercise to the point of fatigue or exhaustion. Hyperthermia may have teratogenic effects on the fetus so pregnant women should avoid hot tubs and saunas.
18. Which of these strategies would nurse Marina include when teaching a pregnant woman about sexual activity? a. You should avoid sexual intercourse during the last 6-8 weeks of your pregnancy b. After your fourth month of pregnancy you should place a pillow under your right hip during intercourse c. Your orgasms will become less intense during the last weeks of pregnancy d. Many women experience decreased sexual desire during their second trimester
18. B. Because of the pressure placed on the vena cava by an enlarging uterus, a pillow should be placed under the right hip of the woman if she is lying on her back during intercourse. This will displace the uterus off the vena cava.
19. When a pregnant couple is over the age of 35, nurse Fe should expect the couple to demonstrate which of these behaviors? a. increased financial concern related to costs associated with the birth b. increased confidence related to previous childbirth experiences c. increased anxiety of physical risk related to maternal age d. moderate anxiety related to uncertainty about fetal well being
19. D. In addition to nursing diagnoses applicable to all pregnant women, the pregnant couple over the age of 35 may have additional concerns about the well-being of their baby as it relates to Down syndrome or other genetic disorders. Most couples over the age of 35 are more financially secure and have fewer concerns related to the cost of a birth. Couples over the age of 35 may have experienced infertility problems, births many years before, or have had problem births.
2. A client has experienced a traumatic amputation and subsequent body image disturbance. In the record, nurse Janine documents the nursing diagnosis of body image disturbance related to changes in appearance secondary to: a. chronic disease b. severe trauma c. loss of body part d. loss of body function
2. C. The client lost a limb. The most appropriate secondary cause is loss of body part. This will be a chronic condition, not necessarily a disease, but the most immediate cause of the body image disturbance is loss of body part. The body part was lost because of trauma, but using loss of body part is much more specific and immediately communicates to all other nurses the cause of the body image disturbance. There will be loss of body function as well that relates back to the loss of the body part.
20. Which of these strategies would nurse Paul include when planning care for a pregnant woman who has a decreased MSAFP (maternal serum alpha-fetoprotein), an increase in hCG (human chorionic gonadotropin), and a decreased Estriol level? a. Refer to the physician b. Tell the woman to increase her folic acid intake c. Refer for amniocentesis d. Order a plasma glucose level
20. A. The combination of results presented in this situation may be the result of a fetus with Down syndrome. A neural tube defect can be detected with MSAFP but once the defect has occurred an increase in folic acid will not change it. Taking folic acid before becoming pregnant and continuing through the pregnancy can be beneficial to prevent neural tube defects. The physician needs to be notified of the results and the nurse could anticipate referral for an amniocentesis.
21. The parents of a preschool child have been given instructions about the Denver II. Which of these statements, if made by the parents, would indicate that they correctly understood the teaching? a. This test will tell me whether or not my child's IQ is normal b. This test will tell me what developmental tasks my child can do today c. This test will measure my child's development d. This will let me know if my child's development is normal or not
21. B. The Denver II is a screening test, not diagnostic. The results indicate what tasks the child was able to perform the day of the test only. It is not an intelligence test so no IQ score is obtained, it does not measure development. The word measure implies a diagnostic result. The test does not determine whether a child's development is not normal. It screens only. If a child has a result other than normal that child either needs to be rescreened or evaluated by a developmental specialist to determine if the development is normal or not.
22. When teaching the parents of toddler-age children about expected developmental milestones, at which age should nurse Yvette tell the parents most children are walking? a. 12 months b. 15 months c. 18 months d. 24 months
22. B. Most children walk between 11 and 15 months of age. To tell the parents that children walk by 12 months of age causes them concern needlessly because their child would actually have until 15 months of age before the nurse would be concerned. All children 18 and 24 months of age should be walking for some time.
23. If a school age child's growth and development is within normal range, which of these developmental stages would nurse Rhea expect to identify? a. Trust b. Industry c. Initiative d. Autonomy
23. C. Industry versus inferiority is the developmental stage of school age children. Trust versus mistrust is the developmental stage of infancy. Initiative versus guilt is the developmental stage of preschoolers, and autonomy versus shame and doubt is the developmental stage of toddlers.
24. When teaching parents about the pros and cons of their children sleeping with them, which of the following information should nurse Alex give the parents? a. If you give your child more attention during the day they will not want to sleep with you at night b. Sleeping with parents can contribute to Sudden Infant Death Syndrome c. Children should never be allowed to sleep with their parents d. You could be accused of sexual abuse if you allow your child to sleep with you
24. B. Research has shown that sleeping with adults can contribute to sudden infant death syndrome. The mechanism is believed to be the rebreathing of carbon dioxide as the sleeping child snuggles against the parent. Increased attention during the day will not stop a child from wanting to sleep with their parent. In some cultures it is the norm for children to sleep with their parents. Some occasions provide reasons a parent might want the child to sleep with them, such as illness, nightmares, or bedroom space. Unless parents want this to become a habit, they will have to take measures to be sure it is only for the duration of the circumstance
25. The teaching plan for a client with hair loss secondary to chemotherapy should include which of the following instructions on obtaining a wig? a. Wait until your hair comes out before purchasing a wig b. Treatments are tax-deductible, but not the wig c. You can purchase a wig at the American Cancer Society d. A beautician should be able to give you tips on how to vary the style
25. D. Beauticians are excellent referral sources for the care and styling of wigs. They are able to show the client how to use combs, clips, and otherwise style and care for the wig. Clients should purchase and begin wearing their wigs before all their hair falls out. This will give them and others a chance to figure out how they want to style it.
3. Which of the following statements, when made by a client with anorexia nervosa, would indicate body image distortion instead of body image dissatisfaction? a. I don't like how my body looks b. I wish I looked like my sister c. I'm sad I can't wear halter tops d. I am so overweight
3. D. Statement D is the only statement that reflects a distorted image of the body. Clients with anorexia nervosa look in the mirror and see someone a lot heavier than they really are. They cannot see that they are too thin.
4. Which of the following questions, when asked by nurse Jessica, assesses for the major defining characteristic of disturbed body image? a. How do you feel about this disability? b. How would you describe your usual mood? c. How does your family feel about your illness? d. Do you feel fearful, anxious, or nervous?
4. C. The major defining characteristic of body image disturbance is verbal or nonverbal negative responses to actual or perceived changes in structure and/or function of the body. Asking how the client feels about their disability will give them a chance to assess whether there is a negative or positive response to the change that has occurred.
5. Which of the following clinical manifestations of the aging immune system should alert nurse Therese to increased susceptibility to illness in elder clients? a. increased autoimmune responses b. increased production of T and B cells c. increased lymphoid tissue d. increased circulating lymphocytes
5. A. Elders experience an increased autoimmune response that puts them at increased risk for such diseases as rheumatoid arthritis and other collagen diseases. The number of T and B cells produced by the body is decreased, making the immune system less efficient. The reduction in T cells may play a role in increased malignancy rates in the elderly. Lymphoid tissue in the elderly is decreased, resulting in lower immune responses. The number of circulating lymphocytes in the elderly is reduced by about 15 percent along with a decline in antibody-antigen reaction making the elder more susceptible to infection.
6. Nurse Jessie should include all of the following information in a teaching plan for elders with altered immune responses except: a. Let me go over some ways to manage stress b. It is normal for seniors to run a low grade temperature c. It is important to eat a balanced diet d. If your arthritis starts bothering you, we can give you something for pain
6. B. Elders tend to have masked signs of inflammation and infection and may not respond to them with as high a temperature or white blood count as a middle age person would. Therefore, nurses need to observe carefully for masked signs of infection and encourage the elder clients to contact their doctor even if they have a low grade temperature.
7. Nurse Jackie is planning to utilize reminiscence with an elder client. The nurse's role in this intervention is: a. remind the client when they repeat themselves b. focus on the happy memories, not the sad ones c. probe for details of memories shared d. use themes or props to stimulate discussion
7. D. Themes or props can be used to stimulate discussion during reminiscence therapy. This can be particularly helpful in group settings. Elder clients should be allowed to repeat themselves during the discussion and not have attention drawn to the repetition. During the process of reminiscence both sad and happy memories are shared. The sharing of both should be encouraged. The nurse should avoid probing or pushing for details. The elder should be allowed to share informally and spontaneously.
8. All of the following statements, when made by an elder client, indicate successful achievement of ego integrity except: a. I think I'll volunteer at the library a couple days a week b. I wish I could change some of the things I've done c. I think I'll take a ceramic class at the senior center d. I would like to help people learn to read
8. B. Ego Integrity versus Despair is the final stage of Erikson's psychosocial development. An indication of despair or self-disgust is manifested by the elder believing life has been too short and futile or that they want a chance to redo life. Statement B is consistent with despair. Signs of ego integrity are manifested by statements or tasks that bring together all the previous phases of the life cycle. Manifestations of successful ego integrity mastery include activities such as volunteering at the library (the elder believes they still have something to offer), continued learning (those in ego integrity remain creative), and assisting others (helping people learn to read is still contributing to society).
9. At the 24-week visit, a pregnant woman demonstrates a less than expected growth in uterine size, easily palpable fetus that can be outlined by the nurse, and absence of fetal ballottement. Nurse Clariver should recognize this is most likely related to the development of: a. Hydramnios b. Oligohydramnios c. amniotic fluid embolism d. macrosomia
9. B. Oligohydramnios occurs when the amount of amniotic fluid is severely reduced. This would result in less than expected growth in the uterus, a fetus that is surrounded by so little amniotic fluid that it is easily palpated and outlined, and the fetus will not be palpable when the examiner does a vaginal exam and pushes against the cervix (ballottement).
