NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client who is taking an antipsychotic medication is preparing for discharge. To facilitate health promotion for this client, what instruction should the nurse provide?
Correct Answer: A
Rationale: Antipsychotic medications improve the thought processes and behaviors of a client with psychotic symptoms, especially a client with schizophrenia. Photosensitivity is a side effect of antipsychotic medications. Maintaining a strict tyramine-restricted diet is applicable to monoamine oxidase inhibitors (MAOIs). Antipsychotics are not used to treat depression. Lithium is a mood stabilizer that requires monitoring of medication blood levels.
Question 2 of 5
Which client does the nurse recognize as having the highest increased risk of developing breast cancer?
Correct Answer: D
Rationale: Family history with two first-degree relatives significantly increases breast cancer risk more than age, pregnancy, or obesity.
Question 3 of 5
Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
Correct Answer: A
Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body.
Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis.
Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in
Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.
Question 4 of 5
The nurse at a community health care clinic is teaching parents about measures to take to prevent and manage obesity in children. The nurse determines that the parents need additional teaching if they indicate that they will implement which measures? Select all that apply.
Correct Answer: A,E
Rationale: Parents can implement several measures to prevent and manage obesity in their children. These measures include not using food as a reward; establishing consistent times for meals and snacks, and not allowing eating inbetween; offering only healthy food options; minimizing trips to fast-food restaurants; keeping unhealthy food out of the house; acting as a role model for children; encouraging the child to do fun, physical activities with the family; and praising the child for making appropriate food choices and increasing physical activity levels.
Question 5 of 5
Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8°F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?
Correct Answer: C
Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.