NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 931:

  On which of the following aspects of the assessment should a nurse who is assessing the health-related physical fitness of a client as part of a health assessment be focused?

  A. agility

  B. speed

  C. body composition

  D. risk factors

  Correct Answer: D

  A health assessment should focus on possible risk factors of the client.

  A risk factor is something that increases a person's chance for illness or injury.

  A health-risk appraisal is an assessment of the total person, including lifestyle and health behaviors.

• Question 932:

  A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized.

  Which of the following should include teaching by the nurse?

  A. Immunizations may be started at any age.

  B. The recommended immunization schedule must be followed exactly.

  C. If a primary series of immunizations is interrupted, the series must be restarted.

  D. This child is at increased risk for reaction to the vaccines, when they are started.

  Correct Answer: A

  While a recommended immunization schedule exists, immunizations may be started at any age.

  An interrupted series may be continued and need not be restarted.

  There is no increased risk for reaction to vaccines due to delay.

• Question 933:

  Which of the following developmental milestones for a 6-month-old child should be screened by the nurse during a routine office visit?

  A. standing while holding something

  B. rolling over

  C. sitting up

  D. creeping

  Correct Answer: B

  Rolling over occurs between 4 and 6 months of age. Sitting up occurs between 7 and 8 months, creeping between 9 and 10 months, and standing between 8 and 10 months.

• Question 934:

  During the health screening of an adolescent, which finding by the nurse requires further teaching?

  A. The client started her first menses 2 years ago.

  B. The client states she is currently on birth control pills.

  C. The client states she recently lost 5 pounds.

  D. The client states she is experiencing growing pains.

  Correct Answer: B

  Because the client is on the pill, she requires further teaching regarding protection against STDs. The other findings are not abnormal for an adolescent.

• Question 935:

  A paraplegic client is in the hospital to be treated for an electrolyte imbalance.

  Which level of care is the client currently receiving?

  A. primary prevention

  B. secondary prevention

  C. tertiary prevention

  D. health promotion

  Correct Answer: B

  This client is receiving secondary prevention. The current focus of health care is on preventive care. Leavell and Clark (1965) described the three levels of preventive care as primary, secondary, and tertiary. Secondary preventive care focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. Examples of activities at this level are carrying out direct nursing actions (for example, providing wound care, giving medications, exercising arms and legs), assessing children for normal growth and development, and encouraging regular medical and dental screenings and care. Primary preventive care is directed toward health promotion and specific protections against illness. Activities at this level might focus on individuals or groups. Examples of primary-level activities are immunizations, family-planning services, teaching breast self-examination, poison-control information, and accident-prevention education. Tertiary preventive care begins after an illness is diagnosed and treated and is aimed at helping rehabilitate clients and restore them to their maximum level of functioning.

• Question 936:

  Which of the following is one of the main goals for Healthy People 2010?

  A. reduction of health care costs

  B. elimination of health disparities

  C. investigation of substance abuse

  D. determination of an acceptable morbidity rate

  Correct Answer: B

  Healthy People 2010 has as its main goal elimination of health disparities among the U.S. population.

  Healthy People 2010 is a set of health objectives for the nation to achieve over the first decade of the

  twenty-first century and was developed by the Surgeon General's office.

  Earlier editions of this report, Healthy People and Healthy People 2000: National Health Promotion and

  Disease Prevention Objectives established national health objectives and served as the basis for the

  development of state and community plans.

• Question 937:

  An appraisal of self-care practices involves an assessment of __________.

  A. all diagnostic tests

  B. home treatment practices, including nurse visits for the sick or disabled

  C. the family's capability to get health insurance

  D. caregiving needs and the potential for strain

  Correct Answer: D

  Short-term stressors impinging on a family include unemployment, being on welfare, the threat of termination, health, hospitalization, convalescence, depression, and suicidal thoughts. Long-term stressors impinging on the family include emotional distance, lack of communication in families (especially within marital relationships), continual geographical movement from one community to the next (so that no stable and sufficient social network is established), a spouse's minimal participation in family life, and excessive and frequent drinking bouts. Family strengths include the presence of a social support system, interest in and capability to provide child care, motivation for employment, and financial self-sufficiency, self-care beliefs, values, health-seeking behaviors, and realistic goals and limitations.

• Question 938:

  Which of the following substances need to be assessed when completing a family health assessment?

  A. coffee, tea, cola, and cocoa

  B. alcohol, tobacco, and illegal substances

  C. medicines prescribed by a physician

  D. all of the above

  Correct Answer: D

  When assessing drug, alcohol, and tobacco practices among family members, a thorough investigation of prescribed, over-the-counter and illegal substance-use practices should be made. Assessment of dietary practices should include the amount and types of food the family eats; the social behaviors associated with dietary practices; and the meal planning, shopping, and preparation practices of the family.

• Question 939:

  The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention.

  What should the nurse include in this teaching plan?

  A. The client should remove all scatter rugs from the floor and minimize clutter.

  B. The client should not get up and move around the house.

  C. The client does not need to install a raised toilet and grab bar because she is able to walk on her own.

  D. The client should wear a robe and socks while walking in the house.

  Correct Answer: A

  Rugs and clutter are a primary cause of falls in the home and should be eliminated if possible to decrease the risk of a fall. The elderly and those with gait issues are at an increased risk for a fall at home. The client should have a raised toilet seat and grab bars available in the bathroom to aid in movement in this potential slippery area of the home. Some clients find it difficult to rise up and down from the toilet and to get in and out of the shower. These items are all important in maintaining safety in the home. The client should not limit her movement within the home unless ordered by the physician. This decreases the ability of the client to perform activities of daily living and hinders the client's return to a normal lifestyle after surgery. The client should not wear baggy clothing such as long robes, and the client should not wear socks on slippery floors. These items can cause the client to trip, slip, or fall.

• Question 940:

  A mother has come to the pediatric clinic concerned about the recent outbreak of West Nile Virus. The ages of her children are 5, 7, and 10. The mother has asked the nurse what she can do to prevent her children from contracting this illness.

  Which piece of information is best to provide the mother with?

  A. The children should wear long sleeves and long pants while outside.

  B. Apply insect repellant containing DEET when the children are outside.

  C. Remove standing water from the property.

  D. All of the above.

  Correct Answer: D

  It is recommended that the children wear insect repellant containing DEET and long-sleeve shirts and long

  pants when they are outside.

  Removing standing water from areas around where the children play can help decrease the number of

  breeding mosquitoes.

  These are the only known methods of prevention at this time.