NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that which aspect of eye function is normal?
Correct Answer: D
Rationale: The correct answer is 'Ocular movements.' Moving the eyes through the six cardinal fields of gaze evaluates the function of the eye muscles, such as the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Normal movement in these fields indicates proper ocular movements. Near vision is assessed using a handheld vision screener, central vision with a Snellen chart, and peripheral vision through the confrontation test.
Therefore, the evaluation of ocular movements through the six cardinal fields of gaze specifically assesses this aspect of eye function.
Choices A, B, and C are incorrect as they pertain to different aspects of vision function that are evaluated using distinct assessment methods, not through the six cardinal fields of gaze.
Question 2 of 5
A client has been taking a drug (Drug A) that is highly metabolized by the cytochrome p-450 system. He has been on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is an inducer of the cytochrome p-450 system. You should monitor this client for:
Correct Answer: C
Rationale: Drug B induces the cytochrome p-450 enzyme system of the liver, thus increasing the metabolism of Drug A, reducing its therapeutic effects.
Question 3 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.
Question 4 of 5
A healthcare professional reviewing the health care record of a client notes documentation of grade 4 muscle strength. The healthcare professional understands that this indicates:
Correct Answer: D
Rationale: Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction.
Therefore, the correct answer is 'Full ROM against gravity with some resistance.'
Choices A, B, and C are incorrect as they do not match the description of muscle strength associated with a grade of 4.
Question 5 of 5
A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?
Correct Answer: A
Rationale: The correct answer is 'Immunizations may be started at any age.' While there is a recommended immunization schedule, immunizations can be initiated at any age. It is essential to emphasize the flexibility in starting immunizations. The statement 'The recommended immunization schedule should be followed' is too rigid; while recommended, there is flexibility in initiation.
Choice C is correct as an interrupted series can be continued without restarting. The statement 'Delaying the start of vaccines does not increase the risk of reaction' is correct. Delaying does not increase the risk of reaction; in fact, it is important to start immunizations to protect the child and the community.