NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?
Correct Answer: D
Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area.
Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood.
Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia.
Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.
Question 2 of 5
A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?
Correct Answer: A
Rationale:
To measure a client's calf circumference accurately, a nurse should place a non-stretchable tape measure around the widest point of the lower leg. It is crucial to ensure that the tape measure is positioned at the same number of centimeters down from a specific landmark, such as the patella, on both legs for consistency. Placing the tape measure 2 inches above the knee (Option
B), 2 inches above the ankle (Option
C), or 2 inches below the patella (Option
D) would not provide an accurate measurement of the calf circumference.
Therefore, these options are incorrect choices.
Question 3 of 5
One drug can alter the absorption of another drug. One drug increases intestinal motility. Which effect does this have on the second drug?
Correct Answer: D
Rationale: Because most oral medications are absorbed in the intestine, increased motility moves the second drug through the system faster, thus decreasing the absorption time and the amount taken up by the intestine.
Question 4 of 5
The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?
Correct Answer: C
Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously.
Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.
Question 5 of 5
A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?
Correct Answer: B
Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.