NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Question 1 of 5
A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?
Correct Answer: B
Rationale:
To assess skin temperature, the nurse would first note the temperature of their own hands.
Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.
Question 2 of 5
An LPN is taking care of an elderly client who experiences the effects of Sundowner's Syndrome almost every evening. Which of these interventions implemented by the nurse would be the most helpful?
Correct Answer: A
Rationale: A nightlight will help reorient the client to his or her surroundings in the evening and nighttime hours. It is best not to challenge the reality of a client experiencing Sundowner's Syndrome, and sedatives may make the effects of the syndrome worse. Every effort should be made to keep the client's room calm, quiet, and peaceful, so noise should be kept to a minimum. Reminding the client that what they are experiencing is not real may cause distress and confusion, while turning on the TV or radio may add unnecessary stimulation instead of promoting a soothing environment.
Question 3 of 5
The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?
Correct Answer: C
Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously.
Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.
Question 4 of 5
When inspecting the ears for cerumen impaction, the nurse checks for which finding?
Correct Answer: D
Rationale: When inspecting the ears for cerumen impaction, the nurse should look for a yellowish or brownish waxy material in the external auditory canal. Cerumen, also known as ear wax, is a secretion that can become impacted due to various reasons. It is produced by the vestigial apocrine sweat glands in the external ear canal. Cerumen may partially obscure the eardrum or totally occlude the ear canal. The other options, redness and swelling of the tympanic membrane, an external auditory canal that is longer than normal, and the presence of edema in the external auditory canal, are not indicative findings of cerumen impaction.
Question 5 of 5
Which reported symptom(s) would indicate a client with Addison's disease has received too much fludrocortisone (Florinef) replacement?
Correct Answer: B
Rationale: Fludrocortisone replacement in Addison's disease involves mimicking the action of aldosterone, a mineralocorticoid that causes the retention of sodium and water. Excessive retention of sodium and water can lead to weight gain.
Therefore, a sudden increase in weight, especially a significant amount like 6 pounds in one week, can indicate an overdose of fludrocortisone.
Choices A, C, and D are incorrect because oily skin and hair, loss of muscle mass, and increased blood glucose levels are not typically associated with excessive fludrocortisone replacement.