Health Promotion and Maintenance NCLEX Questions

Health Promotion and Maintenance NCLEX Questions Related

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A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client?

  • A. If your 2-year-old becomes angry or jealous, you should consider preparing the child for the new sibling rather than seeking psychological intervention.
  • B. Don't worry; every 2-year-old may need time to adjust to a newborn sibling.
  • C. Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.
  • D. A 2-year-old toddler focuses on exploring the environment, but it's important to prepare the child for the new sibling.
Correct Answer: C

Rationale: The correct response by the nurse is, 'Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.' Toddlers are generally unaware of the changes during pregnancy and may not understand the impending arrival of a new sibling. It is essential to prepare the child gradually for the new baby's arrival by making any necessary changes in sleeping arrangements beforehand. Expecting a young child to immediately welcome a new sibling without prior preparation is unrealistic. Option A is incorrect as suggesting psychological intervention prematurely is not appropriate. Option B is incorrect as assuming all 2-year-olds would immediately welcome a newborn is unrealistic. Option D is incorrect as dismissing the concerns without addressing the need for preparation is not appropriate in this situation.

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What is a chemical reaction between drugs before their administration or absorption known as?

  • A. a drug incompatibility
  • B. a side effect
  • C. an adverse event
  • D. an allergic response
Correct Answer: A

Rationale: A chemical reaction between drugs before their administration or absorption is termed a drug incompatibility. This phenomenon commonly occurs when drug solutions are mixed before intravenous administration but can also happen with orally administered drugs. Choices B, C, and D are incorrect because side effects, adverse events, and allergic responses typically occur after the drugs have been administered and absorbed, not before.

The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?

  • A. ''I should eat five or six small meals a day rather than three full meals.''
  • B. ''I need to be sure not to drink liquids with my meals.''
  • C. ''I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.''
  • D. ''I need to avoid eating fried or greasy foods.''
Correct Answer: B

Rationale: To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are: A) Eating five or six small meals a day instead of three full meals is a correct recommendation. C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion. D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.

Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?

  • A. Rectus femoris muscle
  • B. Deltoid muscle
  • C. Gluteal muscle
  • D. Vastus lateralis muscle
Correct Answer: D

Rationale: Vitamin K is administered to newborn infants to help prevent hemorrhagic disease. The best site for intramuscular injection in infants is the vastus lateralis muscle. This site is preferred due to its location away from the sciatic nerve, femoral artery, and vein, reducing the risk of complications. The rectus femoris muscle may be used if necessary; however, it is less favorable than the vastus lateralis due to its proximity to vital structures, making injections there more hazardous. The deltoid muscle is not typically used for IM injections in newborns. The gluteal muscles should be avoided until the child has been walking for at least a year, as they are poorly developed and close to the sciatic nerve.

While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6°F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?

  • A. Notify the registered nurse of the findings.
  • B. Document the findings in the client's medical record.
  • C. Recheck the vital signs in 1 hour.
  • D. Continue collecting subjective and objective data.
Correct Answer: A

Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98°F to 99.6°F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4°F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.

A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expect to note if the bladder is full?

  • A. Dull sounds
  • B. Hyperresonance sounds
  • C. Hypoactive bowel sounds
  • D. An absence of bowel sounds
Correct Answer: A

Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.

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