Health Promotion and Maintenance NCLEX Questions - Nurselytic

Correct Answer: C

Rationale:
Choice 3 not only acknowledges the client's fear but invites more disclosure and discussion. Reflective listening is very therapeutic and in this case acknowledges the woman's unspoken fear that she might become depressed like her mother. When her fears have been acknowledged and she feels that the nurse understands, she will be more open to the teaching or interventions to follow. It is a myth that menopause causes depression, but to say that to this client does not acknowledge the fear she shared with the nurse and gives the impression the nurse doesn't care about her concern. It closes down communication. It is also true that menopause is a normal developmental process. This can certainly be used in teaching but not to address her immediate concern; the client might feel the nurse doesn't think her concern is appropriate because menopause is normal. If women experience depression during menopause, it is usually due to social stresses such as loss of loved ones, loss of roles, caregiver demands, and physical problems.
Choice 4 is true but is a nontherapeutic response in this situation.

Correct Answer: C

Rationale: The correct answer is 'Frequent urination and burning when I urinate are expected.' This statement by the mother indicates a need for further information because these symptoms are not normal and could indicate a urinary tract infection or another issue that needs medical attention. The other choices correctly reflect signs and symptoms that should be reported to the health care provider. Redness, swelling, or tenderness in the legs can indicate a blood clot, and feelings of pelvic fullness or pressure can be signs of a problem. Monitoring temperature is also important to ensure there is no infection or other complications postpartum.

Correct Answer: B

Rationale: A rubella titer of less than 1:8 indicates that the client is not immune to rubella. In such cases, retesting will be necessary during the pregnancy. If the client is found to be non-immune, rubella immunization is required post-delivery.
Therefore, choices A, C, and D are incorrect.
Choice A suggests exposure, which cannot be confirmed by the titer result.
Choice C wrongly implies that the client has not developed immunity, which is not accurate.
Choice D is incorrect as the titer result is not within the normal immune range.

Correct Answer: D

Rationale:
To assess tactile (vocal) fremitus, the nurse palpates the thorax and compares vibrations from side to side as the client repeats the word 'ninety-nine.' This technique helps in evaluating the intensity and symmetry of vibrations felt. Palpating for symmetric chest expansion involves assessing the expansion of the chest during breathing by placing hands on the anterolateral wall. Auscultating the breath sounds over the trachea and larynx is done to assess bronchial breath sounds, while auscultating over the peripheral lung fields is used to assess vesicular breath sounds.

Correct Answer: A

Rationale: Rugs and clutter are a primary cause of falls in the home and should be eliminated if possible to decrease the risk of a fall.