Health Promotion and Maintenance NCLEX PN Questions - Nurselytic

Correct Answer: C

Rationale: The correct answer is a client who states they are not interested. While lack of interest can hinder learning motivation, it is not a physical or mental barrier that directly impacts the learning process. On the other hand, a client who took Ambien® an hour ago may experience drowsiness or impaired cognitive function, affecting their ability to learn. A bipolar client in a manic phase may exhibit symptoms such as racing thoughts, distractibility, and impulsivity, making it challenging for them to focus and engage in the learning process. A client with dysphagia may have difficulty swallowing, which can interfere with their ability to take oral medications or participate in activities that involve swallowing.

Correct Answer: B

Rationale: During a voice test, the nurse should whisper words from the client's side at a distance of 1 to 2 feet from the ear being tested. This distance helps prevent transmission around the head and ensures accurate testing of one ear at a time. By standing close to the client and whispering, the nurse prevents lip-reading and compensatory actions by the client. The client with normal hearing should be able to repeat each word correctly.

Choices A, C, and D are incorrect.
Choice A is wrong as the voice should be whispered, not spoken in a soft tone.
Choice C is inaccurate because a distance of 10 feet is too far for precise testing.
Choice D is incorrect as whispering from a distance of 20 feet would not effectively test the client's hearing.

Correct Answer: A

Rationale: When preparing a client for central line insertion, nursing responsibilities include explaining the procedure to the client, ensuring necessary consents are signed according to the facility policy, and maintaining sterile technique when preparing the equipment and supplies. Advancing the guidewire is typically performed by the practitioner inserting the central line, not the nurse. It requires specialized training and expertise beyond the scope of nursing practice.
Therefore, the correct answer is advancing the guidewire. Option A is the correct answer because it delineates an activity that is not within the usual scope of nursing practice during central line insertion preparation. Options B, C, and D are incorrect as they reflect essential nursing responsibilities in this context.

Correct Answer: C

Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.

Correct Answer: D

Rationale: The guidelines for a fertility workup are to refer after the couple has not conceived after one year of unprotected intercourse. So,
Choice 1 is technically correct, but it doesn't consider the immediate need for the couple to have some counseling.
Choice 4 is the best answer because it gives the couple guidance now and the referral at the appropriate time. If the woman is over the age of 35, an earlier referral, at six to nine months of unprotected intercourse, is appropriate. It is true that the average time it takes a 25-year-old woman to conceive is 5.3 months, but that does not address the concern the client is expressing.
Choice 4 is still the most caring and correct answer. Couples conceive within the first month of unprotected intercourse 20% of the time.