NCLEX Health Promotion and Maintenance Questions
Health Promotion and Maintenance NCLEX Practice Questions
Question 1.
The nurse is teaching the client about smoking cessation. Which client statement indicates a need for further teaching by the nurse?
(a) "Social smoking can still be detrimental to my health."
(b) "E-cigarettes can help me wean off nicotine so I can quit."
(c) "Pack years are calculated by my packs per day multiplied by the number of years I've smoked."
(d) "Nicotine replacement therapy along with a smoking cessation program is the most successful treatment."
Answer:
(b) "E-cigarettes can help me wean off nicotine so I can quit."
Rationale:
E-cigarettes may contain nicotine and other toxins and are not approved for smoking cessation. Although social smoking is intermittent, it can still have an adverse effect on overall health. Option 3 states the correct method to calculate pack years. Nicotine replacement therapy has a success rate of 50 percent to 70 percent and is highest when used in conjunction with a smoking cessation program.
Question 2.
The nurse educator is teaching a group of newly hired nurses about hospice and palliative care. Which statement by the group requires further clarification?
(a) "Palliative care is not limited by specific time periods."
(b) "Hospice clients have a prognosis of 6 months or less to live."
(c) "Palliative care begins when curative treatments have been stopped."
(d) "Hospice care is provided in 60- and 90-day periods and may continue if the client is eligible."
Answer:
(c) "Palliative care begins when curative treatments have been stopped."
Rationale:
When curative treatments or life-prolonging therapies have stopped, hospice may begin. Hospice clients have a prognosis of 6 months or less to live. Care may extend beyond the 60- and 90- day periods if the client meets eligibility requirements. Palliative care does not follow specific time periods. Palliative care consults can be provided concurrent with curative therapies.
Question 3.
The nurse is teaching a client about dietary modifications to control hypertension. Which statement by the client indicates a need for further teaching?
(a) "I can have a cup of fresh fruit as a snack."
(b) "Baked ham is a good dinner choice for me."
(c) "I need to check the label for sodium in ketchup."
(d) "I need to cut out frozen pizza as a fast meal option."
Answer:
(b) "Baked ham is a good dinner choice for me."
Rationale:
Processed foods such as baked ham are among the highest in sodium, along with preserved and pickled foods. Most fresh fruits and vegetables are low in sodium. Condiments tend to be high in sodium, and learning to read labels helps the client identify appropriate diet choices. Frozen pizza and many other frozen prepared foods are high in sodium because they are processed.
Question 4.
The nurse is caring for a pregnant client at 24 weeks. The client voids before the nurse measures the fundal height. Which finding by the nurse would be expected in assessment of this client?
(a) a fundal height of 22 to 26 cm
(b) a fundal height of 27 to 30 cm
(c) a fundal height of 29 to 33 cm
(d) a fundal height of 31 to 34 cm
Answer:
(a) a fundal height of 22 to 26 cm
Rationale:
From gestational weeks (GW) 18 to 30, the height of the fundus in centimeters is approximately the same as the number of weeks of gestation ±2 GW if the client's bladder is empty. With a full bladder, as much as a 3 cm variation is possible.
Question 5.
A mother brings her 6-month-old baby to the nurse practitioner for a routine well-baby check. Which behavior reported by the mother is concerning to the nurse?
(a) looks at self in a mirror
(b) brings things to mouth
(c) does not laugh or make squealing sounds
(d) begins to sit without support
Answer:
(c) does not laugh or make squealing sounds
Rationale:
At 6 months of age the baby should be aware of her surroundings and, when appropriate, laugh and make squealing sounds. The other stated behaviors are considered normal for a 6 month old.
Question 6.
The nurse is teaching an HIV-positive client who just delivered an HIV-positive full-term infant. Which statement by the client indicates a need for further teaching?
(a) "The antiviral medicines will cure my baby in about six months."
(b) "There is a low risk of my baby transmitting the virus to household members."
(c) "I should completely avoid breastfeeding my baby and purchase formula instead."
(d) "Pneumonia and herpes simplex are common secondary infections my baby may develop."
Answer:
(a) "The antiviral medicines will cure my baby in about six months."
Rationale:
The current goal of antiviral therapy is to reduce the viral load for undetectable levels. At this time there is no indication that antiviral therapy cures HIV. There is a low risk of transferring HIV from the infant to other household members. HIV-positive mothers should not breastfeed but instead purchase formula based on the health care provider's guidance. Many secondary infections are common to HIV-positive infants, including pneumonia and herpes simplex. The infant should be closely monitored for these developments.
Question 7.
The nurse is caring for a client with morning sickness who is 8 weeks pregnant with her first child. What should the nurse advise the client to do to manage nausea?
(a) eat an omelet for breakfast to ensure adequate protein intake
(b) eat foods served warm with moderate amounts of spices
(c) consume most of the daily fluid intake early in the day
(d) brush the teeth immediately after eating; this helps get the food taste out that may trigger nausea
Answer:
(d) brush the teeth immediately after eating; this helps get the food taste out that may trigger nausea
Rationale:
The client should brush the teeth immediately after eating. While omelets contain protein, they are often prepared in butter or grease. Fried and high-fat foods should be avoided. Cool foods with little aroma and no spices are preferable. Large fluid intake should be avoided early in the morning and when nauseated, and consumed at other times instead.
Question 8.
Using Naegele's Rule, calculate the estimated date of birth for a client who reports the first day of the last menstrual period was August 7.
(a) May 7
(b) May 14
(c) October 31
(d) November 14
Answer:
(b) May 14
Rationale:
Naegele's Rule is based on accurate recall of the client's last menstrual period. It assumes a regular 28-day cycle. The estimated date of birth is calculated by taking the first day of the last period, subtracting 3 months, and adding 7 days.
Question 9.
The nurse is caring for a client diagnosed with syphilis. The client presents with a widespread, symmetric maculopapular rash on the palms and soles. The nurse understands that the client is in which stage of the infection?
(a) primary syphilis
(b) secondary syphilis
(c) early latent syphilis
(d) latent phase syphilis
Answer:
(b) secondary syphilis
Rationale:
The primary stage of syphilis is characterized by a primary lesion, the chancre, that appears 5 to 90 days after infection. Secondary syphilis occurs 6 weeks to 6 months after the chancre appears and is characterized by a widespread, symmetric maculopapular rash on the palms and soles. An early latent infection is one that was acquired in the preceding year. The latent phase is asymptomatic for most individuals and occurs if left untreated.
Question 10.
The labor and delivery nurse expects which clients to be at high risk for amniotic fluid embolus (AFE)? Select all that apply.
(a) a 27-year-old client with preeclampsia
(b) a healthy 23-year-old anticipating a vaginal delivery
(c) a 42-year-old expecting her second child via cesarean section
(d) a 32-year-old client with diabetes anticipating induced labor
Answer:
(a) a 27-year-old client with preeclampsia
(c) a 42-year-old expecting her second child via cesarean section
(d) a 32-year-old client with diabetes anticipating induced labor
Rationale:
Risk factors for AFE include diabetes, placenta previa or abruption, preeclampsia, eclampsia, advanced age, labor induction, forceps-assisted or cesarean birth, and uterine rupture or cervical laceration.
Question 11.
A nurse is preparing staff education on the developmental stages and milestones in a normally developing fetus. Which information should be included?
(a) The testes at the inguinal ring descend to scrotum at 12 weeks.
(b) The bladder and urethra separate from the rectum at 12 weeks.
(c) The kidneys are in position at 16 weeks with typical shape and plan.
(d) The nostrils reopen and primitive respiratory-like movement begins at 24 weeks.
Answer:
(c) The kidneys are in position at 16 weeks with typical shape and plan.
Rationale:
The kidneys are in position at 16 weeks with typical shape and plan. Testes descend to the scrotum at 24 weeks. The bladder and urethra separate from the rectum at 8 weeks. Primitive respiratory responses begin at 20 weeks.
Question 12.
The nurse is monitoring fetal heart rate (FHR) on a laboring client. Which finding should be reported to the health care provider?
(a) FHR of 154 bpm with moderate variability
(b) FHR of 114 bpm with moderate variability
(c) FHR of 170 bpm lasting more than 10 minutes
(d) FHR of 156 bpm with minimal variability in a premature infant
Answer:
(c) FHR of 170 bpm lasting more than 10 minutes
Rationale:
A FHR of greater than 160 bpm lasting more than 10 minutes may indicate early fetal hypoxemia, fetal cardiac arrhythmias, infection, or fetal anemia. A normal FHR is from 110 to 160 bpm. Moderate variability is considered a normal finding. Minimal variability may occur with prematurity.
Question 13.
The nurse is teaching a new mother about postpartum fatigue (PPF). Which information would the nurse include?
(a) PPF is more common in women with cesarean births.
(b) Fatigue usually improves over the first 6 weeks after birth.
(c) Fatigue can help reduce the incidence of postpartum depression.
(d) Nursing mothers can minimize fatigue by breastfeeding in the side-lying position.
Answer:
(d) Nursing mothers can minimize fatigue by breastfeeding in the side-lying position.
Rationale:
Comfort measures such as side positioning during breastfeeding can help minimize fatigue. There is no evidence that supports PPF as being more common in cesarean births; it is, however, associated with long labor and cesarean births. Fatigue tends to worsen over the first 6 weeks after birth. Symptoms of PPF can be interrelated with postpartum depression.
Question 14.
The nurse is caring for a client with myasthenia gravis (MG) who is 14 weeks pregnant.
Which of the following does the nurse understand about MG in the pregnant client?
(a) Most women with MG tolerate labor poorly unless they are in excellent physical health.
(b) Approximately 25% to 30% of neonates born to women with MG develop neonatal myasthenia.
(c) MG usually goes into remission with younger clients and causes exacerbation in older clients.
(d) Narcotics must be used with caution due to the risk of respiratory depression in clients who are already at risk for respiratory muscle weakness.
Answer:
(d) Narcotics must be used with caution due to the risk of respiratory depression in clients who are already at risk for respiratory muscle weakness.
Rationale:
Most women with MG tolerate labor well as it does not affect smooth muscle. Approximately 10 percent to 15 percent of neonates born to women with MG develop neonatal myasthenia. The response of women with MG is unpredictable and can range from remission to exacerbation to continued stability throughout pregnancy. Clients with MG are already at risk for respiratory muscle weakness; regional anesthesia is preferred.
Question 15.
The nurse is preparing to assess cranial nerve VIII on a client. Which tests will the nurse perform? Select all that apply.
(a) Allen's test
(b) Phalen'stest
(c) the Rinne test
(d) the Weber test
Answer:
(c) the Rinne test
(d) the Weber test
Rationale:
The Rinne test compares bone conduction of sound with air. The Weber test uses a tuning fork to provide lateralization of the sound. Allen's test evaluates the patency of the ulnar and radial arteries by compressing them with the thumbs. Phalen's test involves 90-degree flexion to the wrists and tests for carpal tunnel syndrome.
Question 16.
Which client does the nurse recognize as having the highest increased risk of developing breast cancer?
(a) a 68-year-old client with dense breasts
(b) a 34-year-old client pregnant with her first child
(c) an obese client with a body mass index of 30
(d) a client with two first-degree relatives with breast cancer
Answer:
(a) a 68-year-old client with dense breasts
Rationale:
Clients older than 65 years and those with dense breasts are at the highest increased risk of developing breast cancer. Women who have their first child after age 30 or who are obese are at a low increased risk. A family history of two first-degree relatives with breast cancer is a moderate increase in risk.
Question 17.
A nurse on the oncology unit is preparing to care for a client newly diagnosed with small cell lung cancer. Which statements would the nurse include in client teaching? Select all that apply.
(a) "Avoid aspirin-based products to reduce the risk of bleeding."
(b) "Avoid crowds and report low-grade fever, sore throat, or chills."
(c) "Keep vaccinations current, including live vaccines, to promote wellness."
(d) "Use a soft toothbrush and electric razor to minimize the risk of bleeding."
(e) "Inspect the mouth regularly for sores and ulcers and rinse the mouth after meals."
Answer:
(a) "Avoid aspirin-based products to reduce the risk of bleeding."
(b) "Avoid crowds and report low-grade fever, sore throat, or chills."
(d) "Use a soft toothbrush and electric razor to minimize the risk of bleeding."
Rationale:
The health care provider should be consulted before receiving any vaccinations, and live vaccines should not be given. Avoiding aspirin and using electric razors and soft toothbrushes will help minimize the risk of bleeding. Mouth rinses may be prescribed for thrush and ulcers. Low-grade fever, sore throat, or chills indicate infection and should be reported to the health care provider.
Question 18.
The nurse is teaching a client the proper technique for rising a cone. Which statement should (he nurse include ih (he teaching? Select a((that apply.
(a) "Hold the cane on the affected side."
(b) "Hold the cane on the unaffected side."
(c) "Move the cane at the same time as the affected leg."
(d) "Move the cane at the same time as the unaffected leg."
(e) "Hold the cane 8 to 10 inches from the side of the foot."
Answer:
(b) "Hold the cane on the unaffected side."
(c) "Move the cane at the same time as the affected leg."
Rationale:
Holding the cane on the unaffected side allows the cane to work with the weaker leg. The cane should move in tandem with the affected leg. Holding the cane on the affected side is incorrect technique. Moving the cane at the same time as the unaffected leg will not offer stability. The cane should be held 4 to 6 inches from the side of the foot; holding the cane too far away will not provide stability and may cause the client to fall.
Question 19.
A nurse is caring for a client with dumping syndrome. Which statement by the client indicates a need for further teaching?
(a) "I should lie down after I eat my meals."
(b) "I may experience weakness and dizziness."
(c) "I should eat a low-fat, high-protein, low-carbohydrate diet."
(d) "I should eat small meals and avoid drinking fluids with my meals."
Answer:
(c) "I should eat a low-fat, high-protein, low-carbohydrate diet."
Rationale:
The prescribed diet for dumping syndrome is high in fat and protein and low in carbohydrates. Lying down after meals prevents dumping syndrome. Weakness and dizziness, along with perspiration and tachycardia, are common assessment Findings. Eating small meals and avoiding fluid intake with meals helps minimize symptoms.
Question 20.
The nurse is precepting a student nurse on the medical-surgical unit who is caring for a client with a T-tube. Which statement by the student nurse regarding the care of the tube indicates a need for further teaching?
(a) "I should report a sudden increase in bile output."
(b) "The client should be in a semi-Fowler's position to promote drainage."
(c) "The drainage system should be kept below the level of the gallbladder."
(d) "I will clamp the tube if the client becomes nauseated or begins to vomit."
Answer:
(d) "I will clamp the tube if the client becomes nauseated or begins to vomit."
Rationale:
The T-tube should be clamped before meals and the client observed for nausea, chills, abdominal distention, or discomfort. If nausea or vomiting occurs, the tube should be unclamped. A sudden increase in bile output should be reported to the health care provider. The semi-Fowler's position promotes drainage into the tube, along with keeping the drainage system below the level of the gallbladder.
Question 21.
The nurse is caring for a client with a non-rebreather mask. Which is the priority nursing action when caring for this client?
(a) maintain the mask snugly on the face
(b) adjust flow rate to keep the reservoir bag inflated
(c) ensure that the reservoir bag is not kinked or twisted
(d) ensure that valves open during expiration and close on inhalation
Answer:
(c) ensure that the reservoir bag is not kinked or twisted
Rationale:
If the reservoir bag kinks or twists, the client can suffocate. The mask should fit snugly on the face to avoid loss of oxygen. The flow rate should be adjusted to keep the bag inflated. A properly working mask will have valves opening upon expiration and closing on inhalation.
Question 22.
The nurse is talking to a 67-year-old client who has just retired from the job he's had since age 17 the only job he's ever had. The nurse understands that the client is in which of Erikson's stages?
(a) intimacy versus isolation
(b) ego integrity versus despair
(c) identity versus role confusion
(d) generativity versus stagnation
Answer:
(b) ego integrity versus despair
Rationale:
Clients age 65 - 85 are in the ego integrity versus despair stage. This is a time of reflection on life. Successful clients can look back with satisfaction, while unsuccessful clients may feel as if their lives were wasted. Young adults aged 19-34 years are in the intimacy versus isolation stage. Adolescents aged 12-18 years are in the identity versus role confusion stage. Adults aged 35 - 64 are in the generativity versus stagnation stage.
Question 23.
A community health nurse is lecturing students at a nearby community college about high-risk behavior. Which of the following should the nurse include in the lecture?
(a) Suicide is the most common cause of death in this age group.
(b) Cancer is the third most common cause of death in this age group.
(c) Homicide is the second most common cause of death in this age group.
(d) College-age students are more likely to die from unintentional injuries.
Answer:
(d) College-age students are more likely to die from unintentional injuries.
Rationale:
In the 15 - 24 age group, unintentional injuries are the most common cause of death. This age group is at high risk for drinking and driving, motor vehicle accidents, and other unintentional injuries. Prevention and awareness of alcohol and drug abuse should be included in teaching. Suicide is the second most common cause of death in this age group, with homicide being the third most common.
The nurse should inform the audience about suicide prevention and give the number of a hotline to call if needed. Personal safety should be covered as well, since many college students tend to consume alcohol and walk around campus, night clubs, and other areas late at night when they are vulnerable. Females especially should be taught to not go out alone at night and to never let their drink out of their sight at a party to avoid someone slipping a date-rape drug into their drink.
Question 24.
A client's wife tells the nurse, "I can't believe my husband has high blood pressure. He feels fine. What caused this?" The nurse's response should include which of the following? Select all that apply.
(a) "One-third of people with high blood pressure are not aware of it."
(b) "Clients over 50 years of age are at the highest risk of hypertension."
(c) "Hypertension is more common in Hispanics and Native Americans."
(d) "Hypertension is more prevalent in the southeastern United States."
(e) "Your husband works at a desk job all day, so he does not get as much physical activity as he should."
Answer:
(a) "One-third of people with high blood pressure are not aware of it."
(d) "Hypertension is more prevalent in the southeastern United States."
(e) "Your husband works at a desk job all day, so he does not get as much physical activity as he should."
Rationale:
Hypertension is often called the silent killer because one-third of people with high blood pressure are unaware of it. Hypertension has few signs or symptoms until it causes a stroke or heart attack. Few people experience facial flushing, sweating, and headaches that indicate hypertension until it has progressed to a serious, life-threatening condition.
The southeastern United States is often called the "stroke belt" due to the higher incidence of hypertension and stroke in the region. Lack of physical activity also increases the risk of hypertension. Clients over age 60 are at greatest risk, and hypertension is higher in African Americans, especially those living in the southeast.
Question 25.
A mother brings her 6-month-old child to the clinic for a wellness checkup. The nurse anticipates that the health care provider will order which vaccinations for this client?
(a) DTaP and MMR
(b) Hib and varicella
(c) hepatitis B and DTaP
(d) hepatitis A and MMR
Answer:
(d) hepatitis A and MMR
Rationale:
This child is now due for the third round of hepatitis Band DTaP. Hib is given at 2, 4, and 12 months. MMR and varicella are not given until 12 months of age at the earliest. Hepatitis A is also not given until 12 months of age.
Question 26.
The nurse is working with a client who has just been diagnosed with pancreatic cancer. The client says, "I have so much left to do. I'm too young to die like this." Which of the following stages of Kubler-Ross's five stages of grieving does the nurse recognize in this client?
(a) anger
(b) denial
(c) bargaining
(d) acceptance
(e) depression
Answer:
(a) anger
Rationale:
This client is in the anger stage of grief. During the anger phase, the client may ask questions such as "Why me?" The client feels cheated out of life too early and knows that pancreatic cancer is a harder cancer to treat successfully. In the denial stage, the client refuses to accept the reality of the diagnosis. Denial is a defense mechanism at this stage.
In the bargaining stage, the client may pray that if he is healed, he will become a faithful church-goer or be a better spouse. Acceptance is the final stage, in which the client comes to terms with reality. The client may exhibit signs of emotional detachment. In the depression stage, the client accepts the reality but may feel sadness or fear.
Question 27.
The clinic nurse is talking to a client who has just been prescribed hormone replacement therapy (HRT). Which statement about HRT by the nurse is correct?
(a) "HRT decreases the risk of stroke."
(b) "HRT increases the risk of osteoporosis."
(c) "HRT decreases the risk of deep vein thrombosis."
(d) "HRT increases the risk of coronary artery disease."
Answer:
(d) "HRT increases the risk of coronary artery disease."
Rationale:
HRT increases the risk of coronary artery disease, stroke, deep vein thrombosis, and breast cancer. It lowers the risk of osteoporosis-related fractures. The risks and benefits of HRT must be evaluated by the prescriber, based on the client's medical history.
Question 28.
The nurse is educating a client who is 10 weeks pregnant about prenatal nutrition. The client is of normal weight. Which statement by the client indicates an understanding of weight gain during pregnancy?
(a) "I should gain 15 to 20 pounds."
(b) "I should gain 25 to 35 pounds."
(c) "I should gain 35 to 40 pounds."
(d) "I should gain 40 to 45 pounds."
Answer:
(b) "I should gain 25 to 35 pounds."
Rationale:
Most women of average weight should gain about 25 to 35 pounds during pregnancy. If they are overweight, they should gain a little less, whereas underweight women should gain a little more. Excessive weight gain increases the risk of preeclampsia. Failure to lose extra weight after the baby is born increases the risk of hypertension and diabetes. For most women, 15 to 20 pounds is inadequate weight gain, while a gain of 35 or more pounds is excessive. The client should work with her health care provider to monitor her weight gain and maintain an appropriate weight.
Question 29.
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?
(a) The optimum score is 10.
(b) A baby with poor activity would rate a 1 in that area.
(c) The highest score that each factor may receive is 3.
(d) Scores are obtained 5 minutes after birth and repeated 5 minutes later.
Answer:
(a) The optimum score is 10.
Rationale:
Apgar scores measure five areas: appearance, pulse, grimace, activity, and respiration. The highest score for each item is 2. Therefore, the optimum score is 10. A score of 1 in an area indicates the infant is okay but diminished in that area. The lowest score for an area is 0. Poor activity would rate as 0. Apgar scores are obtained one minute after birth.
Question 30.
The nurse is discussing developmental stages with the mother of a six-month-old infant. Which statement indicates an unexpected deviation from normal development?
(a) The infant is walking alone by 15 months.
(b) The infant waves good-bye by 7 months.
(c) The infant rolls from the tummy to the side at 12 months.
(d) The infant transfers a toy from one hand to the other at age 9 months.
Answer:
(c) The infant rolls from the tummy to the side at 12 months.
Rationale:
Infants should roll from the tummy to the side by 10 months. By age 15 months, infants should be able to walk alone. Waving good-bye should be accomplished by 7 months. Transferring a toy from one hand to the other occurs by 9 months. New parents should be aware of general time frames for achieving motor skills so that they can notify the health care provider if the infant does not achieve milestones.
Question 31.
The nurse is teaching a 28-year-old male client about testicular cancer. Which statement by the client indicates understanding of the nurse's teaching?
(a) "Testicular cancer is one of the hardest cancers to treat and cure."
(b) "Testicular cancer is the most common cancer in men ages 25 - 35."
(c) "A lump larger than a quarter should be reported to my health care provider."
(d) "The best time to perform testicular self-examination is just after bathing because the scrotum is more relaxed."
Answer:
(d) "The best time to perform testicular self-examination is just after bathing because the scrotum is more relaxed."
Rationale:
The best time to perform testicular self-examination is just after bathing because the scrotum is more relaxed. Testicular cancer is one of the most curable cancers. It is most common in men ages 15 to 35. Any lump or swelling regardless of size should be reported to the health care provider.
Question 32.
The nurse is performing an admission assessment on a client. The client states that she has been smoking two packs of cigarettes a day for 20 years. The nurse would chart how many pack years for this client?
(a) 10 pack years
(b) 20 pack years
(c) 30 pack years
(d) 40 pack years
Answer:
(d) 40 pack years
Rationale:
A pack year is one pack of cigarettes smoked daily for one year. This client smokes two packs per day. The calculation is 2 (packs per day) × 20 (years smoking) = 40 pack years. The other calculations are incorrect for this client.
Question 33.
The nurse is providing teaching to a client newly diagnosed with hypertension. The nurse knows that the client understands the teaching when the client selects which menu option?
(a) frozen pizza and a spinach salad
(b) baked chicken with fresh green beans
(c) a ham sandwich with peas and carrots
(d) a can of chicken soup and a grilled cheese sandwich
Answer:
(b) baked chicken with fresh green beans
Rationale:
Clients with hypertension should avoid a high-sodium diet. Baked chicken with fresh green beans is the lowest sodium option listed. Frozen foods and processed foods are among the highest in sodium. While a spinach salad is healthy, the frozen pizza contains far too much sodium. Ham is processed meat, which is very high in sodium. Canned foods, especially soups, are high in sodium unless specifically labeled "low sodium" or "lower in sodium." The nurse should teach the client hidden sources of sodium in the everyday diet.
Question 34.
The nurse is participating in a free community health screening with a group of student nurses. Which statement by a student nurse requires further teaching by the licensed nurse?
(a) "Colorectal cancer screening should begin at age 50."
(b) "Men should have a prostate-specific antigen test starting at age 55."
(c) "High-density lipoprotein should be greater than 50 mg/dL for women."
(d) "Risk factors for hypertension include being over age 60 and leading a sedentary lifestyle."
Answer:
(b) "Men should have a prostate-specific antigen test starting at age 55."
Rationale:
Men should have a prostate-specific antigen test starting at age 50, not 55. Colorectal cancer screening should begin at age 50. High-density lipoprotein should be greater than 50 mg/dL for women. Risk factors for hypertension include being over age 60 and leading a sedentary lifestyle. Depending on the client's family medical history, the health care provider may recommend screening at an earlier age.
Question 35.
The nurse is teaching a newly diagnosed client about Crohn's disease. The nurse understands which barriers may prevent effective client learning? Select all that apply.
(a) language barriers
(b) motivation to learn
(c) lack of a support system
(d) adequate financial resources
(e) cognitive dysfunction, such as schizophrenia
Answer:
(a) language barriers
(c) lack of a support system
(e) cognitive dysfunction, such as schizophrenia
Rationale:
Language barriers, lack of a support system, and cognitive dysfunction are some of the barriers to learning. Low levels of literacy, environment, and cultural or background considerations may impede learning. Motivation to learn and adequate financial resources make it easier for the client to learn.
Question 36.
"Hie nurse is conducting a Health fair at a local high school on reducing high-risk behaviors. Which teaching should the nurse include in the presentation? Select all that apply.
(a) Always buckle up, even for a short trip.
(b) Use approved bike helmets for bike riding.
(c) Do not drive for one hour after drinking alcohol.
(d) Condoms offer full protection against sexually transmitted infections.
(e) Dive into untested waters with the hands fully extended over the head.
Answer:
(a) Always buckle up, even for a short trip.
(b) Use approved bike helmets for bike riding.
Rationale:
Unintentional injuries are the leading cause of death for teenagers. Wearing seatbelts, even on short trips, and using approved helmets when bike riding can help prevent injuries. One hour after the last drink of alcohol is not a safe window for driving, especially when multiple drinks have been consumed. Condoms are not 100 percent effective against sexually transmitted infections, even when used correctly. Abstinence is the only method guaranteed to avoid sexually transmitted infections. Never dive into untested waters, even with the arms over the head to "break" the fall. If the bottom of a body of water is not visible, it should not be considered safe for diving.
Question 37.
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?
(a) is left-hand dominant
(b) clings to caregivers in new situations
(c) walks with assistance of another
(d) says several single words
Answer:
(a) is left-hand dominant
Rationale:
By 2 years of age, a child may use one hand more than the other. The remaining activities are consistent with achievement by a child 18 months of age.
Question 38.
The nurse is teaching a group of student nurses about principles of teaching. Which statement by a student nurse requires further instruction from the licensed nurse?
(a) "A client's living situation can affect his readiness and ability to learn."
(b) "The client's age and developmental stage must be considered when teaching clients."
(c) "Tactile or kinesthetic learners prefer to learn by watching a video or reading a handout."
(d) "I should allow clients to demonstrate their understanding of what they have learned and practice skills."
(e) "Some barriers to learning include financial resources, lack of support systems, and a low level of literacy."
Answer:
(c) "Tactile or kinesthetic learners prefer to learn by watching a video or reading a handout."
Rationale:
Clients who are tactile or kinesthetic learners prefer to learn by touching and doing. If they are learning how to administer insulin injections, they learn better by holding the syringe in their hand as opposed to simply watching a video or reading a handout. A client's living situation can affect his readiness and ability to learn. A client who has visual deficits will have a harder time reading a medication bottle and may be embarrassed about verbalizing his needs.
The age and developmental stage must be considered; teaching a school-age child is much different from teaching a grown adult. Clients should be allowed to demonstrate their understanding of teaching, ask questions, and practice skills if necessary. There are many barriers to learning, including financial resources, lack of support systems, and a low level of literacy.
Question 39.
The nurse is reviewing the medication history for a 24-year-old client in the fertility clinic. Which medication does the nurse understand to be a Category X medication in pregnancy?
(a) metformin
(b) amoxicillin
(c) gabapentin
(d) simvastatin
Answer:
(d) simvastatin
Rationale:
Simvastatin is a Category X medication, meaning it has been proven to have a harmful effect on the human fetus and is contraindicated in pregnancy. The risks outweigh the benefits in Category X drugs. Metformin and amoxicillin are Category B drugs, meaning that animal studies do not demonstrate a risk to the fetus, and no well-controlled studies have been done in pregnant women. Gabapentin is a Category C drug, meaning that animal studies demonstrate a risk to the fetus, but it is possible that the benefits outweigh the risks in pregnant women. Very few drugs are tested in pregnant women due to ethical concerns of conducting clinical trials that may expose the fetus to harm.
Question 40.
A community health nurse is preparing a lecture on lifestyle and risk factors for a college-age audience. The nurse understands that which causes of death are the most common among this age group?
(a) HIV, suicide, unintentional injuries
(b) suicide, cancer, unintentional injuries
(c) suicide, unintentional injuries, homicide
(d) homicide, unintentional injuries, heart disease
Answer:
(c) suicide, unintentional injuries, homicide
Rationale:
Suicide, unintentional injuries, and homicide are the three main causes of death for college- age young adults. HIV is one of the top 10 causes of death in people ages 25 - 34. Cancer is the leading cause of death for people ages 45 - 64. Heart disease is the second-leading cause of death for people ages 45 - 64.
Question 41.
The nurse is caring for a client who is 38 weeks pregnant and plans to breastfeed. This is the client's first child, and she expresses concern about lactation. The nurse tells the client that which measures stimulate lactation? Select all that apply.
(a) breast massage
(b) frequent breastfeeding
(c) pumping breasts between feedings
(d) vigorous exercise one week after birth
(e) applying cold compresses to the breasts
Answer:
(a) breast massage
(b) frequent breastfeeding
(c) pumping breasts between feedings
Rationale:
Breast massage, frequent breastfeeding, and pumping breasts between feedings stimulate lactation in the postpartum client. Vigorous exercise should not be done one week after birth; the client should follow the health care provider's guidelines regarding when vigorous exercise can be resumed. Applying warm, not cold, compresses to the breasts stimulates lactation.
Question 42.
A nurse is preparing to talk about hormone replacement therapy (HRT) to a group of women at a women's fair at the local hospital. Which statements regarding HRT are correct? Select all that apply.
(a) HRT decreases the risk of breast cancer.
(b) HRT decreases the risk of stroke in postmenopausal women.
(c) HRT lowers the risk of bone fractures caused by osteoporosis.
(d) HRT increases the risk of bone fractures caused by osteoporosis.
(e) HRT decreases the risk of coronary artery disease (CAD) in women who do not smoke.
Answer:
(c) HRT lowers the risk of bone fractures caused by osteoporosis.
Rationale:
HRT lowers the risk of bone fractures caused by osteoporosis but increases the risk of breast cancer and stroke. HRT increases the risk of coronary artery disease in all women, especially smokers, who already increase their risk of CAD by smoking.
Question 43.
A pediatric nurse in an ambulatory care clinic is admitting a neonate for the 2-week office visit. Which comment by the mother should alert the nurse to suspect colic?
(a) "My baby looks yellow."
(b) "After feedings, my baby pulls his legs up and cries."
(c) "My baby is quiet and doesn't cry much."
(d) "My baby is alert for brief periods of 10 - 20 minutes at a time."
Answer:
(b) "After feedings, my baby pulls his legs up and cries."
Rationale:
Signs of colic include pulling the legs up and crying after feedings. To determine if this condition needs further investigation, a diary of symptoms should be compiled by the mother and reviewed by the nurse. A baby who looks yellow may be experiencing hyperbilirubinemia. During their first 3 months of life, babies can cry up to 2 hours per day. A quiet child may be experiencing hypothyroidism. Being alert for brief periods of 10 - 20 minutes at a time is expected of normal babies at 2 weeks of age.
Question 44.
A normal, healthy 35-year-old male client visits the doctor's office for a routine annual physical. When auscultating between the first and second interspaces on the anterior chest, the nurse anticipates which type of breath sound?
(a) bronchovesicular
(b) vesicular
(c) bronchial
(d) tracheal
Answer:
(a) bronchovesicular
Rationale:
Located between the first and second interspaces in the anterior chest are bronchovesicular sounds. Normally heard throughout the lung fields are vesicular sounds. Located between the second and third intercostal spaces of the anterior chest are bronchial sounds. Heard over the trachea are tracheal breath sounds.
Question 45.
A mother infected with hepatitis B asks the nurse about the possibility of breastfeeding her neonate. Which response by the nurse would be most appropriate?
(a) "Yes, breastfeeding is an acceptable option."
(b) "No, you should not breastfeed your baby."
(c) "Yes, breastfeeding is an acceptable option once your baby is immunized with the hepatitis B vaccine."
(d) "Bottled formula is just as nutritious for your baby."
Answer:
(c) "Yes, breastfeeding is an acceptable option once your baby is immunized with the hepatitis B vaccine."
Rationale:
Within 12 hours of birth, children born to HBV-infected mothers should receive the hepatitis B vaccine, making breastfeeding a viable option. The second vaccine should be given to the child at 1 - 2 months and the third dose at 6 months of age. By age 9-18 months the infant should be tested for the presence of HBV. Optimal nutrition for newborns consists of exclusive breastfeeding for the first 6 months of age.
Question 46.
A 28-year-old client has just given birth. At one minute the baby appears healthy, with the exception of bluish hands. Which of the following would the nurse midwife pronounce?
(a) The Apgar score is 11.
(b) The Apgar score is 9.
(c) The Apgar score is 6.
(d) The Apgar score is 4.
Answer:
(b) The Apgar score is 9.
Rationale:
Apgar scoring consists of 5 areas (muscle tone, heart rate, reflex response, color, breathing) with a possible score of (a), (b), or for each area. An Apgar of 9 is correct: four of the five categories for this example rate a score of 2 (subtotal of 8) with 1 point for good color with bluish hands (or feet). The maximum score achievable is 10. A score of 4 or 6 will require support, typically in breathing.
Question 47.
The client's first day of her last period was January 24. Which of the following should the nurse tell the client is her expected date of delivery?
(a) September 30
(b) October 31
(c) November 15
(d) December 1
Answer:
(b) October 31
Rationale:
Due date is determined by adding 9 months and 7 days to the first day of the client's last menstrual cycle, making October 31 the correct date. September 30 is one month too early. November 15 and December 1 would make the baby overdue.
Question 48.
The nurse is discussing concerns the parent has with his 3-year-old. The parent identifies limitations in the child's activities. Select all that should be of concern to the nurse.
(a) unable to work simple toys
(b) unable to understand simple instructions
(c) unable to say first and last name
(d) unable to name any colors or numbers
Answer:
(a) unable to work simple toys
(b) unable to understand simple instructions
Rationale:
By the age of 3 a child should be able to work simple toys and understand simple instructions. In contrast, the ability to say the first and last name and to name colors or numbers are milestones that occur at 4 years old.
Question 49.
The nurse is providing education at a senior center. Which of the following measures will the nurse say is most effective in attaining normal blood pressure in a client with hypertension?
(a) eating red meat daily
(b) increasing potassium and calcium intake
(c) increasing fluid intake
(d) decreasing sodium intake
Answer:
(d) decreasing sodium intake
Rationale:
Decreasing sodium intake is an effective way to reduce blood pressure in a client with hypertension. Eating red meat daily, increasing potassium and calcium intake, and increasing fluid intake are not measures that affect blood pressure readings.
Question 50.
A 9-month-old child is registered to attend a local childcare clinic. Upon initial intake, the nurse discovers the child has received the first and second dose of the hepatitis B vaccine. What is the best course of action for the nurse to recommend to the parents?
(a) no action; a third dose of the vaccine is not recommended
(b) immediately inoculate the child given the high risk of not having a third vaccine
(c) wait until the child is 12 months to give the vaccine
(d) schedule the child for the third vaccine at the earliest convenience
Answer:
(d) schedule the child for the third vaccine at the earliest convenience
Rationale:
The nurse should recommend the child receive the third vaccine at the earliest convenience as it should be routinely administered anytime from 6 to 19 months of age. Thereafter, the third dose may be safely administered through the age of 18 years old. A third dose of the hepatitis B vaccine is advisable. The child is not in immediate danger by not having had the third vaccine.
Question 51.
The nurse is teaching a smoking cessation program. He will state that which of the following benefits of quitting appear within one year?
(a) risk of coronary heart disease is the same as that of a nonsmoker
(b) carbon monoxide level in blood drops to normal
(c) risk of dying from lung cancer is about half that of a smoker's
(d) risk of having a stroke is reduced to that of a nonsmoker's
Answer:
(b) carbon monoxide level in blood drops to normal
Rationale:
Within 12 months after quitting, the carbon monoxide level in a smoker's blood drops to normal. At 15 years after quitting, the risk of coronary heart disease is the same as that of a nonsmoker. At 10 years after quitting, the risk of dying from lung cancer is about half that of a smoker's. At 5 to 15 years after quitting, the risk of having a stroke is reduced to that of a nonsmoker's.
Question 52.
The nurse is preparing a community educational presentation. The topic is the leading causes 1 of death for people ages 12 - 19. The nurse knows that which of the following should be presented?
(a) unintentional injuries
(b) cancer
(c) homicide
(d) suicide
Answer:
(a) unintentional injuries
Rationale:
According to the Centers for Disease Control and Prevention, accidents (unintentional injuries) account for nearly one half of all teenage deaths. The other four leading causes of death among teenagers are homicide, suicide, cancer, and heart disease.
Question 53.
The nurse identifies a client's learning preference as visual. Which of the following would be appropriate when teaching the client about insulin injection?
(a) an audiotape
(b) an orange, an insulin syringe, an alcohol wipe, and a bottle of sterile saline
(c) classroom discussion
(d) an instructional pamphlet
Answer:
(d) an instructional pamphlet
Rationale:
The instructional pamphlet is visual, allowing the client to see words and pictures, which is appropriate given the client's preference. The audiotape and classroom discussion are auditory, allowing the client to hear words. The orange/syringe/alcohol wipe/bottle are tactile, allowing the client to touch.