NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
When preparing to assist the healthcare provider in examining a client's skin with the use of a Wood light, what action should the nurse perform?
Correct Answer: A
Rationale: When using a Wood light during a skin examination, the room should be darkened to enhance the visibility of fluorescence. The Wood light emits long-wavelength ultraviolet light, highlighting certain skin conditions. Darkening the room aids in better visualization. Obtaining informed consent is a crucial aspect of healthcare but not directly related to using a Wood light. Obtaining a scalpel and a slide is unnecessary for a noninvasive Wood light examination. Anesthetizing the skin area is not required as the procedure is painless and noninvasive.
Question 2 of 5
When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?
Correct Answer: C
Rationale: The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling.
Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.
Question 3 of 5
A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing which disorder?
Correct Answer: B
Rationale: Leg pain characteristic of peripheral artery disease is known as intermittent claudication. The client can walk only a certain distance before cramping, burning, muscle discomfort, or pain forces them to stop, with the pain subsiding after rest. The pain is reproducible, and as the disease progresses, the client can walk shorter distances before the pain recurs. Ultimately, pain may even occur at rest. Venous insufficiency (
Choice
A) involves impaired blood flow in the veins, leading to swelling and skin changes but not typically pain associated with exercise. Sore muscles from overexertion (
Choice
C) and muscle cramps related to musculoskeletal problems (
Choice
D) do not present with the characteristic pattern of pain associated with peripheral artery disease.
Question 4 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 5 of 5
Levothyroxine (Synthroid) is the drug of choice for thyroid replacement therapy in clients with hypothyroidism because:
Correct Answer: A
Rationale: Levothyroxine is safe and effective with virtually no side effects when dosed properly. A single, daily dose is possible because of the long half-life (7 days). Levothyroxine tablets are available in a wide range of concentrations to meet individual client requirements. Levothyroxine (T4) is a prodrug of T3.