NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
During a routine health screening, the nurse should talk to the parents of a 1-year-old child about which of the following?
Correct Answer: A
Rationale: During a routine health screening for a 1-year-old child, discussing the potential hazards of accidents is crucial. Accidents are the primary source of injury in children and can be life-threatening. Addressing appropriate nutrition now that the child has been weaned from breastfeeding should have already been discussed.
Toilet training is important but is typically addressed at a later age as one year is too early for this milestone. While preventing accidents in the house is important, focusing on the potential hazards of accidents in general is more comprehensive and critical for the child's safety.
Question 2 of 5
A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?
Correct Answer: D
Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there.
Then, the nurse proceeds to listen for bowel sounds in the other quadrants.
Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.
Question 3 of 5
A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?
Correct Answer: C
Rationale: Subjective data are information provided by the client about their symptoms, feelings, or experiences. In this case, the client reporting having a rash is subjective data because it is based on what the client says.
Choices A, B, and D involve observations or measurements made by the nurse (anxious appearance, blood pressure, reflexes), which fall under objective data. Objective data are observable and measurable data obtained through physical examination, vital signs assessment, and laboratory tests.
Question 4 of 5
The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?
Correct Answer: B
Rationale: The correct answer is 'My child has recently taken a few steps but does not seem stable when standing.' By 18 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by this age, a physical therapy evaluation may be necessary. It is normal for an 18-month-old to start using a spoon to eat. However, the use of two-word phrases is not typically expected until 2 years of age. Separation anxiety is a common developmental phase that typically occurs between 6 and 18 months, so it does not require immediate follow-up.
Therefore, the statement about the child not being stable when standing raises a red flag and necessitates further evaluation.
Question 5 of 5
A nurse working in a pediatric clinic and observes the following situations. Which of the following may indicate a delayed child to the nurse?
Correct Answer: A
Rationale: At 12 months a child should at least be 'cruising' (holding on to objects to walk).