NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Question 1 of 5
A child is seen in the health care clinic, and testing for human immunodeficiency virus (HIV) is performed because of the child's exposure to HIV infection. Which home care instruction should the nurse provide to the parents of the child?
Correct Answer: A
Rationale: Parents should avoid sharing toothbrushes to prevent potential HIV transmission through blood or bodily fluids. Immunizations should be kept up to date to protect the child. Blood spills should be cleaned with a paper towel, followed by soap and water, then a bleach solution, not just a rag and air-drying. Washing hands with soap and water is sufficient; bleach is too caustic for skin.
Question 2 of 5
A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.
Question 3 of 5
A patient with bipolar disorder asks the nurse, "Why did I get this illness? I don't want to be sick."? The nurse would best respond with:
Correct Answer: D
Rationale: The correct response is, 'We don't fully understand the cause, but mental illnesses do seem to run in the family.' Current research suggests that while genetics play a role in the development of mental illnesses like bipolar disorder, it is not the sole factor. Environmental influences, life experiences, and other non-genetic factors also contribute significantly to the manifestation of mental disorders.
Choices A, B, and C provide incorrect information that is not supported by current research. Traumatic childhood experiences, contracting a virus during childhood, and an overactive immune system are not established causes of bipolar disorder or mental illnesses in general.
Question 4 of 5
Which of the following statements best describes compartment syndrome?
Correct Answer: B
Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis.
Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome.
Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome.
Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.
Question 5 of 5
A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly?
Correct Answer: B
Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and behind the ears are cleaned. The newborn infant's neck should be washed because formula, lint, and breast milk will often accumulate in the folds of the neck. The hands and arms are then washed. The newborn infant's legs are washed next, with the diaper area being washed last.