NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?
Correct Answer: C
Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image.
Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns.
Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image.
Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.
Question 2 of 5
The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they:
Correct Answer: A
Rationale: Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription.
Choice 2 is incorrect because alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression.
Choice 3 is incorrect because nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkin's lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA crosslinkage.
Choice 4 is incorrect because alkylating agents are non-cell-cycle-specific agents.
Question 3 of 5
A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:
Correct Answer: C
Rationale: Spinnbarkheit is the term for stretchy, elastic cervical mucus at ovulation, indicating fertility. Ferning requires microscopic examination, and inhospitable mucus inhibits sperm motility.
Question 4 of 5
When determining a fetal heart rate (FHR) and noting accelerations from the baseline rate when the fetus is moving, a nurse interprets this finding as:
Correct Answer: A
Rationale: When a nurse notes accelerations from the baseline rate of the fetal heart rate, particularly when they occur with fetal movement, it is considered a reassuring sign. This indicates a healthy response to fetal activity. Reassuring signs in FHR monitoring include an average rate between 120 and 160 beats/min at term, a regular rhythm with slight fluctuations, accelerations from the baseline rate (often associated with fetal movement), and the absence of decreases from the baseline rate.
Choices B, C, and D are incorrect because accelerations in FHR with fetal movement are not indicative of the need to contact the physician, fetal distress, or a nonreassuring sign. These signs would typically be associated with other abnormal FHR patterns that would warrant further assessment and intervention.
Question 5 of 5
Distribution of a drug to various tissues is dependent on the amount of cardiac output to each type of tissue. Which tissue would receive the highest amount of cardiac output and thus the highest amount of a drug?
Correct Answer: D
Rationale: Highly perfused tissue includes all vital organs: the brain, heart, kidneys, adrenal glands, and liver.
Choices 1, 2, and 3 are incorrect because the skin and adipose tissue are poorly perfused, while the skeletal muscle is better perfused.