NCLEX-RN
Health Promotion NCLEX RN Nursing Questions Questions
Extract:
Question 1 of 5
The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What should the nurse do to appropriately test for asterixis?
Correct Answer: C
Rationale: Asterixis, or liver flap, is a rapid, nonrhythmic tremor in hepatic encephalopathy, tested by having the client extend the wrist and fingers. Handwriting is nonspecific, stool color is unrelated, and lab tests do not assess asterixis directly.
Question 2 of 5
The home care nurse suspects that a client's spouse is experiencing caregiver strain. Which action should the nurse take to assess for this condition?
Correct Answer: B
Rationale: Caregiver strain can occur when a client is significantly dependent on the caregiver for personal and health care needs. The nurse gathers data from the client and the caregiver to determine the caregiver's stressors and coping abilities and withholds making any referrals until the assessment is complete and the plan of care is in place. Because the nurse suspects caregiver strain, the nurse fulfills the duty to the client and family by approaching the family with the concern, gathering assessment data, and planning care. The nurse does not expect the client to assess the coping abilities of the caregiver because assessment is part of the nursing process and should not be delegated.
Question 3 of 5
The nurse instructs a client who is hospitalized and on a low-fat diet. Which menu does the nurse provide for the client?
Correct Answer: D
Rationale: Turkey breast without the skin, boiled rice, and strawberries offer the client nourishing foods that are low in fat. Some sources of fat include meats, avocado, salad dressing, mayonnaise, butter, cheese, and bacon. The remaining options contain high-fat foods.
Question 4 of 5
The nurse is instructing a client diagnosed with type 1 diabetes mellitus about the management of hypoglycemic reactions. The nurse instructs the client that hypoglycemia most likely occurs during what time interval after insulin administration?
Correct Answer: A
Rationale: Insulin reactions are most likely to occur during the peak time after insulin administration, when the medication is at its maximum action. Peak action depends on the type of insulin, the amount administered, the injection site, and other factors.
Question 5 of 5
The clinic nurse provides instructions to a client who will begin taking oral contraceptives. Which statement by the client indicates the need for further teaching?
Correct Answer: C
Rationale: The client must use a second birth control method during the first pill cycle of oral contraceptives to ensure protection against pregnancy. Taking the pill at the same time daily, taking a missed pill as soon as remembered, and taking two missed pills as soon as remembered with two the next day are correct actions.