NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?
Correct Answer: D
Rationale: The correct answer is the Wong-Baker Pain Scale. This scale is specifically designed for pediatric clients, including children as young as 3 years old, making it the most appropriate choice for a 4-year-old. It utilizes a simple visual scale with facial expressions that children can easily understand and use to express their pain levels. The FLACC and CRIES Pain Scales are also used for pediatric clients but are more focused on non-verbal cues and specific populations like infants or critically ill children. The McGill Pain Scale, on the other hand, is more complex and uses descriptive words, making it more suitable for adult clients who can better articulate their pain experiences.
Question 2 of 5
When performing the confrontation test to assess peripheral vision, what action should the nurse take?
Correct Answer: D
Rationale: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits.
Choices A, B, and C are incorrect.
Choice A pertains to testing color vision, which is not part of the confrontation test.
Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test.
Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.
Question 3 of 5
A chemical reaction between drugs prior to their administration or absorption is known as:
Correct Answer: A
Rationale: A drug incompatibility occurs when drugs react chemically before administration, potentially reducing efficacy or causing harm. Side effects and adverse events occur post-administration, and allergic responses are immune-mediated.
Question 4 of 5
While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?
Correct Answer: C
Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.
Question 5 of 5
Kleinman's Explanatory Model of Health and Illness is significant because:
Correct Answer: C
Rationale: The anthropologist Kleinman makes a distinction between disease and illness. Disease is the health care professionals' biomedical understanding of the health problem, while illness is the client's personal and unique understanding and definition of what is happening to him. The theorist states that cultural factors determine the importance of the various domains of influence.