NCLEX-RN
NCLEX RN Health Promotion Questions Questions
Extract:
Question 1 of 5
The nurse is teaching a client how to stand on crutches. What information should the nurse give the client related to placement of the crutches?
Correct Answer: B
Rationale: The tripod position for crutches involves placing them 6 to 10 inches to the front and side of the toes, depending on body size, to ensure balance and support. Other distances are either too short or too long for effective crutch use.
Question 2 of 5
A client is diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse places priority on teaching the client about modifications of which risk factor related to this disorder?
Correct Answer: B
Rationale: Buerger's disease is an occlusive disease of the median small arteries and veins. It occurs predominantly among men who are more than 40 years old who smoke cigarettes. A familial tendency is noted, but cigarette smoking is consistently a risk factor. Symptoms of the disease improve with smoking cessation. Exposure to heat, diet low in vitamin C, and excessive water intake are not risk factors.
Question 3 of 5
The labor and delivery nurse notes that the health care provider has rated a newborn's Apgar score as 9. The nurse understands which to be true regarding Apgar scores?
Correct Answer: A
Rationale: The optimal Apgar score is 10. Each factor scores 0-2, and scores are taken at 1 and 5 minutes post-birth.
Question 4 of 5
The mother of a child with celiac disease asks the nurse how long a special diet is necessary. The nurse provides which instruction to the mother to promote dietary compliance?
Correct Answer: A
Rationale: Celiac disease is characterized by intolerance to gluten, the protein component of wheat, barley, rye, and oats. The main nursing consideration with celiac disease is helping the child adhere to dietary management. The treatment of celiac disease consists primarily of dietary management with a gluten-free diet. Options 2 and 4 are true statements, but they do not answer the question that the client is asking. Children with untreated celiac disease may have lactose intolerance, which usually improves with gluten withdrawal. Additional sodium does not prevent celiac crisis. Low levels of potassium, calcium, and magnesium are most likely to be present. Nutritional deficiencies resulting from malabsorption are treated with appropriate supplements.
Question 5 of 5
The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for additional teaching?
Correct Answer: C
Rationale: Autonomic hyperreflexia generally occurs in a client with a spinal cord injury after the period of spinal shock resolves. It occurs with injuries above T6 and cervical injuries. Signs/symptoms of autonomic hyperreflexia include headache, congestion, flushed skin above the level of injury and cold skin below it, diaphoresis, nausea, and anxiety. Fever and chest pain are not associated with this condition.