Questions 9

NCLEX-PN

NCLEX-PN Test Bank

Health Promotion and Maintenance NCLEX Questions Questions

Question 1 of 5

When planning for the physical assessment of the woman, the nurse ensures that which occurs?

Correct Answer: A

Rationale: In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman's genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.

Question 2 of 5

A nurse is telling a pregnant client about the signs that must be reported to the health care provider. The nurse tells the client that the health care provider should be contacted if which occurs?

Correct Answer: A

Rationale: During pregnancy, it is important to be aware of danger signs that warrant contacting the healthcare provider. Puffiness of the face, especially around the eyes, can indicate a serious condition like preeclampsia. Other danger signs include vaginal bleeding, rupture of membranes, severe abdominal pain, visual disturbances, persistent vomiting, and changes in fetal movements. Morning sickness, breast tenderness, and urinary frequency are common symptoms of pregnancy and are not typically concerning unless they become severe or persistent, and do not usually require immediate medical attention.

Question 3 of 5

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse makes which determination?

Correct Answer: A

Rationale: A hepatitis B screen is performed to identify antigens in maternal blood. If antigens are present, it indicates that the mother is a carrier, and the newborn will need to receive hepatitis immune globulin and vaccine soon after birth to prevent transmission. Therefore, choice A is correct. Choices B and C are incorrect because the presence of antigens indicates a positive result, not a negative one or the absence of hepatitis B in the mother. Choice D is incorrect as it suggests the client needs to receive the hepatitis B series of vaccines, which is not the immediate action required when antigens are found in the maternal blood.

Question 4 of 5

When preparing to listen to a client's breath sounds, what technique should a nurse use?

Correct Answer: D

Rationale: When preparing to listen to a client's breath sounds, a nurse should ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little more deeply than usual but to stop if feeling dizzy. The nurse should use the flat diaphragm end-piece of the stethoscope, holding it firmly on the chest wall. By using the diaphragm, the nurse can listen for at least one full respiration in each location, moving from side to side to compare sounds. This technique ensures a systematic and thorough assessment of lung sounds. Choice A is correct as it includes the proper positioning of the client and specifies the use of the diaphragm of the stethoscope. Choice B is incorrect as both lungs should be auscultated systematically, starting from the top and moving down. Choice C is incorrect as deep breaths, not shallow ones, are recommended for an accurate assessment of breath sounds.

Question 5 of 5

While assessing a client's skin, the nurse notes the presence of several large red-blue and purple areas on the client's body that do not blanch when pressure is applied. The nurse documents this finding using which term?

Correct Answer: D

Rationale: Ecchymosis refers to a large patch of capillary bleeding into the tissues, commonly known as a bruise. The color of such an area changes from red-blue or purple to green, yellow, and brown before the area disappears. Pressure on the area will not cause it to blanch. Psoriasis is characterized by scaly erythematous patches with silvery scales on top, usually found on specific areas like the scalp, elbows, knees, low back, and anogenital area. Anasarca is bilateral or generalized edema, indicating a central problem like congestive heart failure or kidney failure. Petechiae are tiny purple or red spots resulting from tiny hemorrhages within the dermal and subdermal areas. Therefore, in this case, the correct term to document the described finding is Ecchymosis.

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