Health Promotion and Maintenance NCLEX PN Questions - Nurselytic

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.

Correct Answer: D

Rationale:
To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment.
Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.

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: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits.

Choices A, B, and C are incorrect.
Choice A pertains to testing color vision, which is not part of the confrontation test.
Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test.
Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.

Correct Answer: D

Rationale: Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option
A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option
B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option
C) is unnecessary and can lead to unnecessary anxiety for the client.