Questions 9

NCLEX-PN

NCLEX-PN Test Bank

Health Promotion and Maintenance NCLEX PN Questions Questions

Question 1 of 5

A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

Correct Answer: B

Rationale: A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.

Question 2 of 5

When assessing the carotid artery of a client with cardiovascular disease, what action should a nurse perform?

Correct Answer: C

Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.

Question 3 of 5

The LPN has been asked to help a client taking Risperdal with activities of daily living in the morning. Which of these tasks is most likely to be potentially impacted by this medication?

Correct Answer: C

Rationale: The correct answer is 'getting out of bed to use the bathroom.' Risperdal can cause orthostatic hypotension, leading to a drop in blood pressure when changing positions from lying down to standing up. This effect increases the risk of falls, emphasizing the need to assist the client with this task to prevent potential harm. Choices A, B, and D are less likely to be directly impacted by the medication, unlike the significant risk of orthostatic hypotension associated with changing positions.

Question 4 of 5

A nurse assisting with data collection for a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding using which terminology?

Correct Answer: A

Rationale: The correct term for generalized edema over the entire body is 'Anasarca.' Anasarca is indicative of a systemic issue such as congestive heart failure or kidney failure. It does not refer to increased vascularity of the skin tissue. Ecchymosis is a bruise caused by capillary bleeding into the tissues, unrelated to generalized edema. Unilateral edema is swelling in a specific area of the body, not the generalized edema observed in anasarca.

Question 5 of 5

An allergic reaction is classified as what type of pharmacological effect?

Correct Answer: C

Rationale: An allergic reaction is classified as an adverse effect because it is an unintended response to a medication that requires treatment. A side effect is an undesired but somewhat expected reaction to a drug that does not necessarily need intervention. Incompatibility refers to an unsuitable combination of substances that leads to an adverse effect. A therapeutic effect is the desired and intended outcome of a medication.

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