NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the nurse assess for? Select all that apply.
Correct Answer: A,C,F
Rationale: Scoliosis is a lateral curvature of the spine.
To ensure early detection and treatment, children aged 9 through 15 years should be screened for scoliosis; those at greatest risk are girls from 10 years of age through adolescence. The child should be unclothed or wearing only underpants so that the chest, back, and hips can be clearly seen. The child should stand with the weight equally on both feet, legs straight, and arms hanging loosely at the sides. The nurse then observes for the signs of scoliosis. These signs include nonpainful lateral curvature of the spine, a curve with one turn (C curve) or two compensating curves (S curve), lateral deviation and rotation of each vertebra, unequal shoulder heights, unequal waist angles, unequal rib prominences and chest asymmetry, and unequal rib heights.
Question 2 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.
Question 3 of 5
The clinic nurse instructs a client diagnosed with diabetes mellitus about preventing diabetic ketoacidosis on days when the client is feeling ill. Which statement by the client indicates the need for further teaching?
Correct Answer: A
Rationale: Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. The client needs to be instructed to continue taking insulin, even if vomiting and unable to eat, to prevent ketoacidosis. It is important to self-monitor blood glucose more frequently during illness (every 2 to 4 hours). If the premeal blood glucose is more than 250 mg/dL, the client should test for urine ketones and contact the primary health care provider. Calling the doctor if ill for more than 24 hours, consuming 10 to 15 g of carbohydrates every 1 to 2 hours, and drinking small quantities of fluid every 15 to 30 minutes are accurate interventions to maintain hydration and glucose control during illness.
Question 4 of 5
A client diagnosed with nephrolithiasis arrives at the clinic for a follow-up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of calcium oxalate. On the basis of this analysis, the nurse should tell the client that it is best to avoid which food to minimize the risk of recurrence?
Correct Answer: D
Rationale: Many kidney stones are composed of calcium oxalate. Foods that raise urinary oxalate excretion and predispose to stone formation include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, almonds, cashews, rhubarb, and tea. Pasta, lentils, and lettuce are not high in oxalates and are generally safe for clients with calcium oxalate stones.
Question 5 of 5
A client diagnosed with anxiety disorder is prescribed buspirone orally. When the client reports that it is difficult to swallow the tablets, the nurse provides which instruction to promote compliance?
Correct Answer: A
Rationale: Buspirone tablets may be crushed and administered without regard to meals, making this the most effective instruction to promote compliance for a client who finds swallowing difficult. Mixing the tablet uncrushed in applesauce does not address the swallowing issue. Buspirone is not available in liquid form, and calling the primary health care provider for a medication change is premature before trying this intervention.