NCLEX Test Review Questions on Health Promotion and Maintenance Answers and Rationale

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1. B. No matter how far the client’s pregnancy has progressed by the time of her first prenatal visit, the nurse should teach about danger signs during pregnancy so the client can identify and report them early, helping to avoid complications. The nurse should discuss other topics just before they’re expected to occur.

2. C. Freud defined the first 2 years of life as the oral stage and suggested that the mouth is the primary source of satisfaction for the developing child. Erikson posited that infancy (from birth to age 12 months) is the stage of trust versus mistrust, during which the infant learns to deal with the environment through the emergence of trustfulness or mistrust. Initiative versus guilt corresponds to Freud’s phallic stage. Autonomy versus shame and doubt corresponds to Freud’s anal/sensory stage. Industry versus inferiority corresponds to Freud’s latency period.

3. C. Nipple discharge, breast nodules, nipple retraction, and lymphadenopathy may be signs of breast cancer and should be reported. Mammary duct ectasia may cause fever, nipple discharge, breast nodules, erythema of the breast, and itching. Breast changes during menstruation are normal; for this reason, women should examine their breasts 4 to 7 days after the menstrual period ends, when the breasts are least congested. Fever and erythema of the breast may indicate a breast abscess.

4. B. The squeezing action of the contractions during labor enhances fetal lung maturity. Infants who aren’t subjected to contractions are at an increased risk for developing respiratory distress. The type of birth has nothing to do with temperature or glucose stability, and acrocyanosis is a normal finding.

5. C. Hepatitis A can be caused by consuming contaminated water, milk, or food — especially shellfish from contaminated water. Hepatitis B is caused by blood and sexual contact with an infected person. Hepatitis C is usually caused by contact with infected blood, including receiving blood transfusions.

6. C. Fetal heartbeat and fetal movement on palpation are considered positive signs of pregnancy because they can’t be caused by any other condition

7. D. Skin tests for tuberculosis require a delay in reading the reaction to allow sufficient time for antibodies to respond to the injected antigen. The nurse should read the client’s PPD test for size of induration 48 hours after injection. Reading it earlier may lead to a false-negative result.

8. C. When a person ages, the skin heals more slowly, loses elasticity, develops wrinkles, and undergoes pigmentation changes. Hair loses pigmentation and hair and nails grow more slowly. Sweat gland production diminishes.

9. C. During early adolescence, a child may become moody. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.

10. C. According to Erikson, an 11-year-old is working through the stage of industry versus inferiority. Chronic illness may interfere with this stage of development in an 11-year-old child. Intimacy is the developmental task of a young adult. Trust is the developmental task to be achieved during infancy. Identity is the developmental task of adolescence.

11. A. Oxytocin nasal spray should be administered while the client is 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.

12. A. In the first trimester, fetal heart sounds are loudest in the area of maximum intensity, just above the client’s symphysis pubis at the midline. Fetal heart sounds aren’t heard as well in the other locations.

13. B. After a vasectomy, sterilization isn’t ensured until the client’s sperm count measures zero. This usually requires 6 to 36 ejaculations. Having intercourse immediately after the procedure or as soon as discomfort disappears may lead to pregnancy.

14. A. Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further.

15.B. The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. These signs aren’t indicative of heart failure. The client doesn’t need to be seen or admitted for delivery.

16. B. Asian Americans have the lowest risk of obesity and diabetes mellitus from the options provided.  Native Americans, African Americans, and Hispanic Americans have a high risk of obesity and diabetes mellitus.

17. A. A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg, spinach (3½ oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium.

18. D. The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium.

19. B. The nurse should counsel the client to keep the total cholesterol level under 200 mg/dL. This will aid in the prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life.

20. D. In the test result for glycosylated hemoglobin A1c, 7% or less indicates good control, 7% to 8% indicates fair control, and 8% or higher indicates poor control. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

21. B. Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet.

22. C. Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Fish is also naturally lower in fat. Cream cheese is a high-fat food.

23. B. Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.

24. D. The type of planning and instruction required varies with each individual and the type of surgery. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Deep-breathing exercises are taught in the preoperative period.

25. A. By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Option B occurs at the end of the ninth week. 

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