Health Promotion and Maintenance NCLEX PN Questions - Nurselytic

Correct Answer: D

Rationale: Administering aspirin would be inappropriate in this situation. Aspirin should not be recommended for children due to the increased risk of Reye's syndrome, a serious condition.

Choices A, B, and C are all appropriate measures for managing teething discomfort in infants. Allowing the child to chew on a cooled teething ring can help soothe the gums, massaging the child's gums gently can provide relief, and administering acetaminophen is a suitable option for pain relief in infants with teething discomfort. Aspirin is contraindicated in children with viral infections due to the risk of Reye's syndrome, a potentially fatal condition affecting the brain and liver.
Therefore, recommending aspirin to the mother would not be appropriate in this case.

Correct Answer: D

Rationale: The correct answer is Accommodation. Accommodation is the process by which the eye adjusts its focus to see objects at different distances. When the pupils get larger when the client looks at an object in the distance and become smaller when looking at a nearby object, it indicates the normal functioning of the eye's accommodation mechanism. Myopia refers to nearsightedness, where distant objects appear blurry. Hyperopia refers to farsightedness, where close objects appear blurry. Photophobia is an abnormal sensitivity to light.
Therefore, the correct term to document the finding of the pupils adjusting based on the distance of the object is 'Accommodation.'

Correct Answer: D

Rationale: The nurse performs the Allen test to determine the patency of the radial and ulnar arteries. During the test, the nurse applies pressure over the client's ulnar and radial arteries simultaneously. The client is then asked to open and close the hand repeatedly, causing the hand to blanch. Subsequently, the nurse releases pressure from the ulnar artery while compressing the radial artery and checks the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, it indicates that the ulnar artery is insufficient, suggesting that the radial artery should not be used for obtaining a blood specimen.
Choice A (Capillaries) is incorrect as the Allen test assesses the patency of larger arteries, not capillaries.
Choice B (Pedal pulses) is incorrect as the Allen test specifically evaluates the radial and ulnar arteries, not the pedal pulses in the foot.
Choice C (Femoral arteries) is incorrect as the Allen test focuses on the radial and ulnar arteries in the hand, not the femoral arteries in the leg.

Correct Answer: C

Rationale: For maximum effectiveness, teach the client about the disorder at the client's level of understanding.

Correct Answer: C

Rationale:
To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint.
Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I.
Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve).
Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.