NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
The LPN is caring for a 9-month-old infant. Which of these behaviors exhibited by the child warrants further investigation?
Correct Answer: C
Rationale: The correct answer is that the child does not respond to her own name. By 9 months, children should be babbling simple words, crawling, and responding to their name. Not responding to one's name can be an early indicator of a potential developmental delay, warranting further investigation. Preferring crawling over walking, being distressed by new adults, and babbling 'mama' and 'dada' are typical behaviors for a 9-month-old and do not necessarily require immediate concern.
Question 2 of 5
A nurse palpates a client’s radial pulse, noting the rate, rhythm, and force, and concludes that the client’s pulse is normal. Which notation would the nurse make in the client’s record to document the force of the client’s pulse?
Correct Answer: C
Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+ for a bounding pulse, 3+ for an increased pulse, 2+ for a normal pulse, and 1+ for a weak pulse. In this case, the nurse would grade the client’s pulse as 2+ based on the description of a normal pulse.
Therefore, the correct notation for the force of the client’s pulse is '2+' as it indicates a normal pulse.
Choices A, B, and D are incorrect as they represent different levels of pulse force that do not align with the description given in the scenario.
Question 3 of 5
When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?
Correct Answer: B
Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the first 3 hours. Somnolence is a rare side effect.
Question 4 of 5
During a genital examination of a male client, a nurse notices wrinkled skin on the penis and scrotum. What should the nurse do based on this finding?
Correct Answer: A
Rationale: The penile skin typically appears wrinkled and hairless, without lesions, during a normal examination. Also, the scrotal skin naturally has a wrinkled appearance known as rugae. It is common for the left half of the scrotum to be positioned lower than the right, indicating normal asymmetry. Given these normal variations, the nurse should document the finding of wrinkled skin on the penis and scrotum. Checking for penile discharge or palpating for a mass in the scrotum is not indicated based on the presence of wrinkled skin, as this is a normal finding. Obtaining additional subjective data focusing on a scrotal abnormality is unnecessary since the wrinkled appearance is typical.
Question 5 of 5
When a client and their family are facing the end stage of a terminal illness, where might they be best served?
Correct Answer: C
Rationale: When a client and their family are facing the end stage of a terminal illness, they are best served by Hospice. Hospice offers a more humanized alternative care for dying clients compared to hospitals, focusing on comfort and quality of life in the final stages of life. It provides a specialized interdisciplinary team of health care professionals who work together to manage client care.
Choices A, B, and D are incorrect because a rehabilitation center focuses on physical therapy, an extended care facility provides long-term care for activities of daily living, and a crisis intervention center deals with immediate psychological or social crises, none of which cater to the specific needs of clients facing the end stage of a terminal illness.