NCLEX PRACTICE QUESTIONS - Health Promotion and Maintenace

Before Birth
• Early and regular antepartal (before-birth) care is critical. First trimester health directly influences the development of organs in embryo and fetus.
• To identify risks, nurses need both subjective (client's) and objective (the nurse's own) assessment data.
• Prescribed medications, over-the-counter drugs, alcohol and tobacco may lead to problems for the fetus and woman.
• Pregnancy diet must include increased calcium, protein, iron and folic acid.
• If the client's situation warrants, suggest ways to adapt activity, employment, and travel.
• It is helpful if the woman can have the same support person throughout pregnancy and birthing classes.

Labor
• Maintain safety and asepsis (sterilize instruments; wear gown, gloves, mask) through the labor and birth process to reduce risks to mother and fetus/newborn.
• Ideally, same caregivers stay through all stages of labor.
• Recognize urgent signs and act promptly.
• Constantly assess and analyze problems to prioritize actions.
• Reinforce the childbirth preparation techniques practiced by the couple during pregnancy.
• Effective teaching during labor must be flexible. Mother will have shorter attention span, increasing discomfort, and emotional responses to labor.
• Promote privacy of the woman and support person as much as possible.
• Respect the cultural and religious beliefs of the woman and partner.
• Involve the family in the birth process as noted in their birth plan or special requests.
• Provide for the woman's needs and comfort.
• Communicate caring and concern to the woman and her family through therapeutic techniques.
• Document assessments, changes in condition and care as promptly as possible.

Postpartum
• Teach (by demonstration and praise) self assessment and care. Start soon after birth.
• The newborn is first of all a family member.
• Share your assessments and plans with parents; welcome their input.
• Respect culture and religious beliefs of the family.
• Praise the parent's skills.
• Media and pamphlets are useful teaching aids if the parent has a chance to discuss them.

Visits and Teachings
• Mothers are discharged quickly, so you must teach accordingly.
• Home visits and follow-up telephone calls let the nurse and parents discuss adaptations, questions and concerns.
• Postpartum teaching should include women's health promotion.
• The adolescent mother benefits from developmentally appropriate teaching and referral to community resources, including parenting classes.

Growth and Development
• Normally proceed in a regular fashion from simple to complex and in cephalocaudal and proximodistal patterns.
• Are orderly, directional, predictable, interdependent and complex processes.
• Are unique to individuals and their genetic potential.
• Occur through conflict and adaptation.
• Growth and development are impacted by genetics, environment, health status, nutrition, culture, and family structures and practices.
• Growth should be measured and evaluated at regular intervals throughout childhood.
• Deviations from normal growth and development should be thoroughly investigated and treated as quickly as possible.
• In the care of children, key concepts are anticipatory guidance and prevention of disease.
• Major developmental tasks of infancy are: increase in mobility, separation, and establishment of trusting relationships.
• In both toddlerhood and adolescence, hallmarks are development of independence and further separation.
• Children and adolescents grow rapidly, so nurses must stress optimum nutrition and give anticipatory guidance related to nutrition.
• In children over one year of age, the leading cause of death is injuries.

Elder Adults
• Elder adults must adjust to lessening physical and cognitive abilities. Over 85% have some type of chronic disease.
• When elder adults experience cognitive changes, check for possible substance abuse or polypharmacy.
• Cognitive impairment can be acute and reversible, or it can be chronic and irreversible.
• Up to 60% of older adults have some impairment in performance of activities of daily living.
• Some physiologic changes are a normal part of the aging process and do not signal disease.
• Elder adults need more time to complete tasks.
• Age is a weak predictor of survival in traumatic injury and critical illness.

Health Risks in Elder Adults
• Major health problems typically include cardiovascular, cerebrovascular, and respiratory diseases; diabetes; and cancer.
• The elder adult will change social roles, and these changes may affect psychological health, leading to depression.
• Elder adults need the same nutrition as other adults, but more bulk and fiber, calcium, and vitamins C and A.
• Contraindications for estrogen replacement therapy include
 hypertension
 thrombophlebitis
 cardiac dysfunction
 family history of breast or uterine cancer
• Elder adults clear drugs from kidney and liver more slowly; so medications have longer half-lives, and they can bring on side effects and toxicity at lower doses.

Health Promotion: Health Assessment
• Measure vital signs when the client is at rest
• Compare both sides of the body for symmetry
• Assess the systems related to the client’s major complaint first
• Offer rest periods if client becomes tired
• Culture and religious beliefs may play a role in observed differences
• Warm hands and equipment such as stethoscope before touching client
• Tell client what you are going to do before touching client
• Normal variations exist among clients and there is a range of normalcy for all physical findings
• Maintain the client’s privacy throughout the examination
• Control for environmental factors which may distort findings
• Check equipment prior to exam for functioning
• Consider growth and developmental needs when assessing specific age groups
• Integrate client teaching throughout the exam
Vasculature
• Compare blood pressure in arms left versus right
• Compare blood pressure with client lying, sitting and standing

Lungs - Airway
• Anemic patients may never become cyanotic
• Polycythemic patients may be cyanotic, even when oxygenation is normal
• Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology.
• Cyanosis indicates decreased available oxygen. Etiology can be either peripheral or central in origin.
• Wheezes indicates narrowing/inflammatory process of lower airways
• Stridor harsh sound produced near larynx by vibration of structures in upper airway. Classic "barky cough"
• Crackles or rales adventitious sounds, usually on inspiration and indicating inflammation

Breast
• Breast tissue shrinks with menopause
• Teach client breast self examination (illustration )

Abdomen - Reproductive System
• Auscultation should be performed before palpation to prevent distortion of bowel sounds
• Tightening of abdominal muscles hinders accuracy of palpation and auscultation
• Warm hands before touching client’s abdomen.
• Men breathe abdominally; women breathe costally.
• Auscultate all four quadrants for bowel sounds
• Auscultate abdomen between meals
Musculoskeletal
• Older adults walk with smaller steps and need a wider base of support

Neurological
• Glasgow Coma Score
 not valid in patients who have used alcohol or other mind-altering drugs
 possibly not valid in patients who are hypoglycemic, in shock, or hypothermic (below 34C)
 should be compared to total of 10 when client is intubated
• Reflexes are normally less brisk or even absent in older clients
• Reflex response diminishes in the lower extremities before the upper extremities are affected
• Absent reflexes may indicate neuropathy or lower motor neuron disorder
• Hyperactive reflexes suggest an upper motor neuron disorder

Teaching client and family
• Teaching-learning process mirrors the nursing process
• Select teaching strategies that are compatible with the client’s learning style, age, culture, level of education
• Client teaching should be multi-sensory
• Always confirm the client’s understanding of the information presented
• Teaching must be geared to the level of the learner
• Repeat key information and summarize main points at intervals
• Explain medical terminology in lay terms
• Determine the client’s learning style and gear teaching methods to using that style
• Sequence information the way the client will use it
• Be concrete and use the simplest words and the shortest sentences when teaching low literacy clients, or any client under stress

TEST QUESTIONS
1. A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?


A) Discharge the client from home health care related to noncompliance

B) Notify the health care provider of the client's failure to follow prescribed diet

C) Discuss diet with the client to learn the reasons for not following the diet

D) Make a referral to Meals-on-Wheels
The correct answer is C: Discuss diet with client to learn the reasons for not following the diet
When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the health care provider, it is best to have a complete understanding of the client''s behavior and feelings as a basis for future teaching and intervention.

2. A client states, "People think I’m no good, you know what I mean?" Which of these responses would be most therapeutic?

A) "Well people often take their own feelings of inadequacy out on others."

B) "I think you’re good. So you see, there’s one person who likes you."

C) "I’m not sure what you mean. Tell me a bit more about that."

D) "Let's discuss this to see the reasons to create this impression on people?"
The correct answer is C: "I’m not sure what you mean. Tell me a bit more about that."
Therapeutic communication technique that elicits more information is delivered in an open non-judgmental fashion.

3. A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis?

A) Noncompliance related to medication side effects

B) Knowledge deficit related to misunderstanding of disease state

C) Defensive coping related to chronic illness

D) Altered health maintenance related to occupation
The correct answer is A: Noncompliance related to medication side effects
The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen from side effects, not a lack of knowledge about the disease process.

4. An appropriate goal for a client with anxiety would be to

A) Ventilate anxious feelings to the nurse

B) Establish contact with reality

C) Learn self-help techniques

D) Become desensitized to past trauma
The correct answer is C: Learn self-help techniques
Exploring alternative coping mechanisms will decrease present anxiety to a manageable level. Assisting the client to learn self-help techniques will assist in learning to cope with anxiety.

5. The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?

A) Focus on the child's needs and recovery

B) Explain the cause of the child's illness

C) Acknowledge that early care would have been better

D) Accept their feelings without judgment
The correct answer is D: Accept their feelings without judgment
Parents often blame themselves for their child''s illness. Feeling helpless and angry is normal and these feelings must be accepted.

6. While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform?

A) Measure the length of the mass

B) Auscultate the mass

C) Percuss the mass

D) Palpate the mass
The correct answer is B: Auscultate the mass
Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the health care provider. The mass should not be palpated because of the risk of rupture.

7. The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children?

A) Growth problems will occur if the fracture involves the periosteum

B) Epiphyseal fractures often interrupt a child's normal growth pattern

C) Children usually heal very quickly, so growth problems are rare

D) Adequate blood supply to the bone prevents growth delay after fractures
The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth pattern
The epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause growth arrest in either longitudinal growth of the limb or in progressive deformity if the plate is involved. An epiphyseal fracture is serious because it can interrupt and alter growth.

8. When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?

A) Competitive board games with older children

B) Playing with their own toys along side with other children

C) Playing alone with hand held computer games

D) Playing cooperatively with other preschoolers
The correct answer is D: Playing cooperatively with other preschoolers
Cooperative play is typical of the preschool period.

9. A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the bestreality orientation for this client?

A) "Good morning. Do you remember where you are?"

B) "Hello. My name is Elaine Jones and I am your nurse for today."

C) "How are you today? Remember, you're in the hospital."

D) "Good morning. You’re in the hospital. I am your nurse Elaine Jones."
The correct answer is D: "Good morning. You’re in the hospital. I am your nurse Elaine Jones."
As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes time, location and the caregivers name.

10. The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning?

A) Performance on written tests

B) Responses to verbal questions

C) Completion of a mailed survey

D) Reported behavioral changes
The correct answer is D: Reported behavioral changes
If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.

11. The nurse is planning care for an 18 month-old child. Which action should be included in the child's care?

A) Hold and cuddle the child frequently

B) Encourage the child to feed himself finger food

C) Allow the child to walk independently on the nursing unit

D) Engage the child in games with other children
The correct answer is B: Encourage the child to feed himself finger food
According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddler to assert his budding sense of control.

12. When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?

A) Biofeedback

B) Deep breathing

C) Distraction

D) Imagery
The correct answer is B: Deep breathing
Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.

13. While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best?

A) "That's OK, its all right to skip your medication now and then."

B) "I will have to call your doctor and report this."

C) "Is there a reason why you don't want to take your medicine?"

D) "Do you understand the consequences of refusing your prescribed treatment?"
The correct answer is C: "Is there a reason why you don't want to take your medicine?"
When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

14. The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?

A) April 8

B) January 15

C) February 11

D) December 23
The correct answer is D: December 23
Naegele''s rule: add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery.

15. A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that

A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events

B) Detaching or dissociating in this way postpones painful feelings

C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict

D) To isolate the feelings in this way reduces conflict within the client and with others
The correct answer is A: Such fantasies can gratify unconscious wishes or prepare for anticipated future events
Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratifying unconscious wishes.

16. When screening children for scoliosis, at what time of development would the nurse expect early signs to appear?

A) Prenatally on ultrasound

B) In early infancy

C) When the child begins to bear weight

D) During the preadolescent growth spurt
The correct answer is D: During the preadolescent growth spurt
Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt. It is more common in females than in males.

17. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?

A) Hold a rattle

B) Bang two blocks

C) Drink from a cup

D) Wave "bye-bye"
The correct answer is A: Hold a rattle
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.

18. When teaching a 10 year-old child about their impending heart surgery, which form of explaination meets the developmental needs of this age child?

A) Provide a verbal explanation just prior to the surgery

B) Provide the child with a booklet to read about the surgery

C) Introduce the child to another child who had heart surgery 3 days ago

D) Explain the surgery using a model of the heart
The correct answer is D: Explain the surgery using a model of the heart
According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using something concrete, like a model will help the child understand the explanation of the heart surgery.

19. A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?

A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room

B) Ask the client if there are second thoughts about having the procedure

C) Notify the anesthesia department and the surgeon of the client's refusal

D) Ask the client if the preference would be to remove the dentures in the operating room receiving area
The correct answer is D: Ask the client if the preference would be to remove the dentures in the operating room receiving area
Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client''s sense of self-esteem and self-concept.

20. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?

A) Formula or breast milk

B) Dilute nonfat dry milk

C) Warmed fruit juice

D) Fluoridated tap water
The correct answer is A: Formula or breast milk
Formula or breast milk are the perfect food and source of nutrients and liquids up until 1 year.