NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Question 1 of 5
A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination in which manner?
Correct Answer: D
Rationale: Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option C) is unnecessary and can lead to unnecessary anxiety for the client.
Question 2 of 5
While assisting with data collection, the client informs the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing which disorder?
Correct Answer: D
Rationale: The correct answer is 'Dysphagia.' Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia refers to a loss of appetite, not difficulty swallowing. Eructation is the medical term for belching, not difficulty swallowing. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid, not difficulty swallowing.
Question 3 of 5
A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?
Correct Answer: D
Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.
Question 4 of 5
When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?
Correct Answer: B
Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.
Question 5 of 5
During a routine office visit, which of the following developmental milestones should the nurse screen for in a 6-month-old child?
Correct Answer: B
Rationale: The correct developmental milestone for a 6-month-old child that should be screened during a routine office visit is rolling over. At this age, infants typically start rolling over from their stomach to their back and vice versa. Sitting up usually occurs between 7 and 8 months, creeping between 9 and 10 months, and standing while holding something between 8 and 10 months. Therefore, choices A, C, and D are developmentally appropriate but not typically expected at 6 months of age.