NCLEX-RN
NCLEX RN Health Promotion and Maintenance Practice Questions Questions
Extract:
Question 1 of 5
The nurse is percussing the anterior thorax and the abdomen for tones and expects to note dullness in which anatomic location? (Refer to figure.)
Correct Answer: C
Rationale: Percussion involves tapping the body with the fingertips to set the underlying structures in motion and thus produce a sound. Dullness will be noted over the liver, located in the upper right quadrant of the abdomen and beneath the lower ribs on the right side. Tympany is the most common percussion tone heard in the abdomen and is caused by the presence of gas. Resonance is the percussion tone heard between the ribs.
Question 2 of 5
The nurse is reviewing home care instructions with a client who has been diagnosed with type 1 diabetes mellitus and has a history of diabetic ketoacidosis (DKA). The client's spouse is present when the instructions are given. Which statement by the spouse indicates that further teaching is necessary?
Correct Answer: A
Rationale: Diabetic ketoacidosis (DK
A) is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. Infection and the stopping of insulin are precipitating factors for DKA. Nausea and abdominal pain that last more than 1 or 2 days need to be reported to the primary health care provider because these signs/symptoms may be indicative of DKA. Withholding insulin during vomiting can exacerbate DKA and is incorrect.
Question 3 of 5
A first-time parent is discussing developmental milestones with a nurse. The nurse tells the client she can reasonably expect her child to achieve which of the following by the time the child is 2 years old?
Correct Answer: D
Rationale: By age 2, children typically say several single words. Hand dominance emerges later, clinging is earlier, and walking is independent by 2.
Question 4 of 5
The nurse is teaching health education classes to a group of expectant parents, and the topic is preventing cognitive impairment caused by congenital hypothyroidism. What should the nurse tell the parents is the most effective means of promoting early intervention?
Correct Answer: B
Rationale: Congenital hypothyroidism is a common preventable cause of cognitive impairment. Neonatal screening is the only means of early diagnosis followed by intervention and the subsequent prevention of cognitive impairment. Newborn infants are screened for congenital hypothyroidism before discharge from the newborn nursery and before 7 days of life. Treatment is begun immediately, if necessary. Vitamin intake and adequate protein will not specifically prevent this disorder. Alcohol consumption during pregnancy needs to be restricted rather than just limited.
Question 5 of 5
The nurse determines that the client with atherosclerosis understands dietary modifications to lower the risk of heart disease if which food selection is made?
Correct Answer: B
Rationale:
To lower the risk of heart disease, the diet should be low in saturated fat with the appropriate number of total calories. The diet should include less red meat (roast beef, cheeseburger) and more white meat with the skin removed. Dairy products used should be low in fat, and foods with high amounts of empty calories (white gravy) should be avoided.