NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A 58-year-old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?
Correct Answer: D
Rationale: The erythrocyte sedimentation rate (ESR) measures levels of inflammation in the body. Elevated ESR levels are commonly seen in autoimmune conditions like rheumatoid arthritis due to the presence of inflammation. In women over 50 years old, a normal ESR is typically below 30 mm/hr.
Therefore, a result of 40 mm/hr is more indicative of arthritis in a 58-year-old individual.
Choices A, B, and C are below the normal ESR range for a woman of this age and would not be as strongly associated with arthritis.
Question 2 of 5
A client has entered disseminated intravascular coagulation (DIC) after becoming extremely ill after surgery. Which of the following laboratory findings would the nurse expect to see with this client?
Correct Answer: B
Rationale: In disseminated intravascular coagulation (DI
C), a client experiences widespread clotting throughout the body, leading to the depletion of clotting factors and platelets. A prolonged prothrombin time (PT) is a common finding in DIC. The PT measures the extrinsic pathway of the clotting cascade and reflects how quickly blood can clot. In DIC, the consumption of clotting factors results in a prolonged PT, indicating impaired clotting ability. Elevated fibrinogen levels (
Choice
A) are typically seen in the early stages of DIC due to the body's attempt to compensate for clot breakdown. Elevated platelet count (
Choice
C) is not a typical finding in DIC as platelets are consumed during the widespread clotting. A depressed d-dimer level (
Choice
D) is also not expected in DIC as d-dimer levels are elevated due to the breakdown of fibrin clots.
Therefore, the correct answer is a prolonged PT.
Question 3 of 5
A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?
Correct Answer: B
Rationale: Late decelerations refer to a pattern where the baby's heart rate decreases during contractions and does not return to normal until after the contraction ends. This is considered a non-reassuring sign as it indicates potential fetal distress. Late decelerations are associated with uteroplacental insufficiency, and immediate medical attention is required. Variable decelerations (
Choice
A) are abrupt, unpredictable decreases in the fetal heart rate, usually associated with cord compression. Early decelerations (
Choice
C) are usually benign and mirror the contraction pattern. Accelerations (
Choice
D) are reassuring signs of fetal well-being, characterized by an increase in the fetal heart rate.
Question 4 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 5 of 5
A client is receiving education on cholesterol. Which of the following statements from the client indicates the need for further teaching?
Correct Answer: C
Rationale: The correct answer is, 'It is better for me to have high LDL levels and low HDL levels.' This statement indicates a need for further teaching because high LDL levels contribute to atherosclerosis, while high HDL levels can protect against heart disease. The client should understand the importance of lowering LDL levels and increasing HDL levels to maintain good heart health.
Choice A is correct as desiring HDL levels over 50 is a positive goal.
Choice B is correct as it reflects the ideal scenario of high HDL and low LDL levels.
Choice D is correct as a total cholesterol below 200 is a common goal for heart health.
Therefore,
Choice C is incorrect as it suggests an opposite and unhealthy relationship between LDL and HDL levels.