NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Question 1 of 5
A nurse assisting with data collection plans to assess tactile (vocal) fremitus. The nurse performs this by using which technique?
Correct Answer: D
Rationale:
To assess tactile (vocal) fremitus, the nurse palpates the thorax and compares vibrations from side to side as the client repeats the word 'ninety-nine.' This technique helps in evaluating the intensity and symmetry of vibrations felt. Palpating for symmetric chest expansion involves assessing the expansion of the chest during breathing by placing hands on the anterolateral wall. Auscultating the breath sounds over the trachea and larynx is done to assess bronchial breath sounds, while auscultating over the peripheral lung fields is used to assess vesicular breath sounds.
Question 2 of 5
When a client wishes to improve her appearance by removing excess skin from her face and neck, the nurse should provide teaching regarding which of the following procedures?
Correct Answer: D
Rationale: Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a facelift. Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne, and pigment from tattoos. Rhinoplasty is performed to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids.
Question 3 of 5
A nurse assisting with data collection is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which action does the nurse take to test this nerve?
Correct Answer: D
Rationale:
To test the cochlear portion of the acoustic nerve (cranial nerve VIII), the nurse should have the client close their eyes and indicate when a ticking watch is heard as the nurse moves the watch closer to the client's ear. This action assesses the client's ability to perceive auditory stimuli, as the cochlear portion of the acoustic nerve is responsible for hearing.
Choices A, B, and C are incorrect. Asking the client to raise their eyebrows to check for symmetry is a method to test the facial nerve (cranial nerve VII). Asking the client to clench their teeth and palpating the masseter muscles tests the motor component of the trigeminal nerve. Having the client identify light and sharp touch on both sides of the face is a way to test the sensory component of the trigeminal nerve (cranial nerve V).
Question 4 of 5
A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?
Correct Answer: D
Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant.
Therefore, the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary in this situation. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, while green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.
Question 5 of 5
When a nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign, what does this indicate?
Correct Answer: A
Rationale: The correct interpretation of the Chadwick sign is that the cervix appears violet in color. This sign is a probable sign of pregnancy, characterized by the violet coloration of the cervix due to increased vascularity of the pelvic organs. It is not a definitive positive sign of pregnancy but rather a probable one.
Choices B and D are incorrect as cervical softening is known as the Goodell sign, and thinning of the cervix is referred to as the Hegar sign. These signs are also probable signs of pregnancy, but they do not specifically indicate the Chadwick sign.