Health Promotion and Maintenance NCLEX Questions Answers and Rationale

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1.    Answer D. Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated.
2.    Answer D. Providing information for the client is the best technique for a new diagnosis.
3.    Answer C. After birth, the infant of a diabetic mother is often hypoglycemic.
4.    Answer A. This change would be most indicative of a potential complication with (BPH) benign prostate hypertrophy.
5.    Answer A. Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus, which is a possible cause of the deceleration.
6.    Answer B. This is a convenient method for administering medications to an infant. Option D is partially correct however, the infant is never placed in a reclining position during a procedure due to a potential aspiration.
7.    Answer C. Tactile stimulation is imperative for an infant’s normal emotional development. After the trauma of surgery, sensory deprivation can cause failure to thrive.
8.    Answer A. Average circumference of the head for a neonate ranges between 32 to 36 cm. An increase in size may indicate hydrocephaly or increased intracranial pressure.
9.    Answer A. Threatening a child with abandonment will destroy the child’s trust in his family.
10.    Answer D. Undescended testicles make the client high risk for testicular cancer. Mumps, inguinal hernia in childhood, orchitis, and testicular cancer in the contra lateral testis are other predisposing factors.
11.    Answer 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 provider. The mass should not be palpated because of the risk of rupture.
12.    Answer D. Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.
13.    Answer A. Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.
14.    Answer C. 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.
15.    Answer A.  The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
16.    Answer B. The nose and ears of the aging client actually become longer and broader. The chin line is also altered. Wrinkles on the face become more pronounced and tend to take on the general mood of the client over the years. For example laugh or frown wrinkles about the eyebrows, lips, cheeks, and outer edges of the eye orbit. The change in the androgen-estrogen ration causes an increase in growth of facial hair in most elder adults. The aging process shortens the platysma muscle, which contributes to neck wrinkles.
17.    Answer  A. Oxidative enzyme levels decrease in the elderly, which affects the disposition of medication and can alter the therapeutic effects of medication. Alcohol has a smaller water distribution level in the elderly, resulting in higher blood alcohol levels. Alcohol also interacts with various drugs to either potentate or interfere with their effects. Magnesium is contained in a lot of medications elder clients routinely obtain over the counter. Magnesium toxicity is a real concern. Albumin is the major drug-binding protein. Decreased levels of serum albumin mean that higher levels of the drug remain free and that there are less therapeutic effects and increased drug interactions.
18.    Answer A. The nurse should anticipate that the infant may have fetal alcohol syndrome and should assess for signs and symptoms of it. These include the characteristics listed in choice A.
19.    Answer A. Four-year-olds are egocentric and interested in having the focus on themselves. They will not be interested in what it feels like to other children. Preschoolers are concrete thinkers and would literally interpret any analogies so they are not helpful in explaining procedures. Assurance of confidential communication is most appropriate for the adolescent. In addition, confidentiality is not maintained if the child plans to harm themselves, harm someone else, or discloses abuse.
20.    Answer  D. 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.
21.    Answer D. 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.
22.    Answer B. Epiphyseal fractures often interrupt a child’s normal growth pattern
23.    Answer is D. As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes time, location and the caregivers name.
24.    Answer D. Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a face lift. Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne, and pigment from tattoos. Rhinoplasty is done to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids.

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