Health Promotion and Maintenance NCLEX PN Questions - Nurselytic

Correct Answer: D

Rationale: The correct answer is Accommodation. Accommodation is the process by which the eye adjusts its focus to see objects at different distances. When the pupils get larger when the client looks at an object in the distance and become smaller when looking at a nearby object, it indicates the normal functioning of the eye's accommodation mechanism. Myopia refers to nearsightedness, where distant objects appear blurry. Hyperopia refers to farsightedness, where close objects appear blurry. Photophobia is an abnormal sensitivity to light.
Therefore, the correct term to document the finding of the pupils adjusting based on the distance of the object is 'Accommodation.'

Correct Answer: A

Rationale: Serotonin syndrome, caused by an excess of serotonin, typically presents with symptoms such as altered mental status (confusion), neuromuscular abnormalities (tremors), and autonomic dysfunction (fever). Edema, which refers to swelling caused by fluid retention in the body tissues, is not a common symptom associated with serotonin syndrome.
Therefore, the correct answer is 'edema.'


Choice A, 'edema,' is the correct answer as it is not typically seen in serotonin syndrome.
Choice B, 'fever,' is a symptom of serotonin syndrome, as it can cause autonomic dysfunction.
Choice C, 'confusion,' is a common symptom due to altered mental status in serotonin syndrome.
Choice D, 'tremors,' is also a common symptom due to neuromuscular abnormalities in serotonin syndrome.

Correct Answer: D

Rationale:
To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size and strength. The correct method involves asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands.
Choice A, asking the client to stick out the tongue and watching for tremors, is used to assess cranial nerve XII (hypoglossal nerve).
Choice C, depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah', is the technique for examining cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve).
Choice B, touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex, is used to evaluate cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve), not cranial nerve XI.

Correct Answer: B

Rationale: The Rights of Medication Administration include the right client, right drug, right dose, right route, and right time. An additional right that is sometimes included is the right documentation. The correct answer includes the essential rights that must be ensured during medication administration.
Choice A is incorrect as 'right explanation' is not part of the traditional Rights of Medication Administration.
Choice B is incorrect as 'right explanation' is not included, and choice C is missing the right route.
Choice D is incorrect as it lacks the right dose and right route.

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.