NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 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 2 of 5
Mrs. F has been diagnosed with hyperparathyroidism. Which of the following complications is Mrs. F at highest risk of developing?
Correct Answer: D
Rationale: The parathyroid glands regulate calcium, vitamin D, and phosphorus in the body. Hyperparathyroidism leads to excessive production of parathyroid hormone, causing the release of calcium from bones into the bloodstream, resulting in elevated blood calcium levels, known as hypercalcemia. This puts individuals at risk of developing complications such as kidney stones, bone pain, osteoporosis, and neuropsychiatric symptoms. The other options, hyponatremia, hypocalcemia, and hypermagnesemia, are not directly associated with hyperparathyroidism. Hyponatremia is low sodium levels in the blood, hypocalcemia is low calcium levels, and hypermagnesemia is high magnesium levels, which are not typically seen in hyperparathyroidism.
Question 3 of 5
The nurse caring for a client in labor should plan to assess the fetal heart rate (FHR) at which specific times? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Assessment of the mother and fetus is continuous during the process of labor. However, for all clients, the FHR needs to be assessed before ambulation; immediately after vaginal examinations, rupture of the membranes, or any other invasive procedure; and before the administration of oxytocin because these activities or situations can cause alterations in the FHR. The FHR is also assessed in between contractions, during the contraction, and for at least 30 seconds after the contraction. It is not necessary to assess the FHR before turning the client to her side.
Question 4 of 5
Mrs. G is seen for follow-up after testing for chronically high blood glucose levels. Her physician diagnoses her with type 1 diabetes. Which of the following information is part of this client's education about this condition?
Correct Answer: C
Rationale: Type 1 diabetes is an autoimmune condition where the immune system attacks and destroys the beta cells in the pancreas, leading to a lack of insulin production. Insulin is essential for regulating blood glucose levels and enabling cells to use glucose for energy. Understanding that type 1 diabetes results from the destruction of beta cells helps patients comprehend the need for insulin replacement therapy.
Choices A and B are incorrect as type 1 diabetes is not primarily caused by diet or exercise habits.
Choice D is incorrect because type 1 diabetes is not about the body's cells rejecting insulin but rather the lack of insulin production due to beta cell destruction.
Question 5 of 5
The nurse is assigned to care for a client being admitted with a diagnosis of cirrhosis and ascites. Which dietary measure should the nurse expect to be prescribed for the client?
Correct Answer: A
Rationale: If the client has ascites, sodium and possibly fluids would be restricted in the diet. The client should maintain a normal amount of fat intake. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The total daily calories should range between 2000 and 3000 . The diet should provide ample protein to rebuild tissue but not an amount that will precipitate hepatic encephalopathy.