Health Promotion and Maintenance NCLEX Test Prep Answers and Rationale

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1. A. Black males have the highest incidence of esophageal cancer. It’s more common in Black, Japanese, and Chinese males than in White males.
2. C. To palpate the maxillary sinuses, the nurse places the hands on either side of the client’s nose below the cheekbone (zygomatic bone).
3. C. Babies lose approximately 10% of their birth weight during the first 3 to4 days, due to loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established.
4. C. It isn’t within a nurse’s cope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training
5. C. In order to detect a breast tumor early, the National Cancer Institute and the American Cancer Society recommend annual mammography for women older than age 40.
6. B. The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown.
7. A. Oxytocin nasal spray should be administered while the clients s sitting with her head in a vertical position. A nasal preparation must not be administered with the client lying down or the head tilted back because this could cause aspiration.
8. C. During early adolescence, a child may become moody. Frequent anger and combativeness are more typical of middle adolescence.
9. A. Breast bud development – elevation of the nipple and areola to form a breast bud – is the first sing of sexual maturity in girls.
10. A. A toddler’s increasing autonomy’s commonly expressed by negativism. They’re unrealiable in expressing pain- they response just as strongly to painless procedures as they do to painful ones.
11. D. The 10 year old girls is most likely to have scoliosis. Scoliosis is five times more common in girls than boys, and its peak age of incidence is between ages 8 and 15.
12. C. Most infants can sit up without support by age 8 months.
13. A. In a child, the Eustachian tubes are short and lie in a horizontal plane, promoting entry of nasopharyngeal secretions into the tubes and thus setting the stage for otitis media.
14. D. The symptothermal method of family planning combines basal body temperature measurement with analysis of cervical mucus changes to determine the fertile period more accurately and thus identify safe and unsafe periods of sexual intercourse.
15. B. Diabetic clients must exercise atleast three times per week to meet the goals of planned exercise – in lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride level, reducing blood pressure, and minimizing stress.
16. A. An Apgar score of 8 indicates that the neonate has made a good transitional to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.
17. B. Sensory deficits could cause a geriatric client to have difficulty retaining knowledge about prescribed medications.
18. D. Primary prevention involves promoting health and helping clients achieve maximum wellness. Primary preventive measures are designed to prevent or delay the onset of specific illnesses; typically, these measures include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer.
19. C. The nurse can use previous problem-solving strategies to assess an adult’s developmental stage as it relates to intellectual functioning.
20. B. The nurse should document the rate, rhythm, and amplitude of a client’s pulse. Pitch, timing, and intensity aren’t associated with pulse assessment.

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