NCLEX Review for Health Promotion and Maintenance (ANSWERS & RATIONALE)

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1. B. One of the two indicators that the goal for implementing new coping patterns has been met is a willingness and ability to resume self-care responsibilities. Statement B shows that the client is taking care of their wig, a new self-care responsibility.

2. C. The client lost a limb. The most appropriate secondary cause is loss of body part. This will be a chronic condition, not necessarily a disease, but the most immediate cause of the body image disturbance is loss of body part. The body part was lost because of trauma, but using loss of body part is much more specific and immediately communicates to all other nurses the cause of the body image disturbance. There will be loss of body function as well that relates back to the loss of the body part.

3. D. Statement D is the only statement that reflects a distorted image of the body. Clients with anorexia nervosa look in the mirror and see someone a lot heavier than they really are. They cannot see that they are too thin.

4. C. The major defining characteristic of body image disturbance is verbal or nonverbal negative responses to actual or perceived changes in structure and/or function of the body. Asking how the client feels about their disability will give them a chance to assess whether there is a negative or positive response to the change that has occurred.

5. A. Elders experience an increased autoimmune response that puts them at increased risk for such diseases as rheumatoid arthritis and other collagen diseases. The number of T and B cells produced by the body is decreased, making the immune system less efficient. The reduction in T cells may play a role in increased malignancy rates in the elderly. Lymphoid tissue in the elderly is decreased, resulting in lower immune responses. The number of circulating lymphocytes in the elderly is reduced by about 15 percent along with a decline in antibody-antigen reaction making the elder more susceptible to infection.

6. B. Elders tend to have masked signs of inflammation and infection and may not respond to them with as high a temperature or white blood count as a middle age person would. Therefore, nurses need to observe carefully for masked signs of infection and encourage the elder clients to contact their doctor even if they have a low grade temperature.

7. D. Themes or props can be used to stimulate discussion during reminiscence therapy. This can be particularly helpful in group settings. Elder clients should be allowed to repeat themselves during the discussion and not have attention drawn to the repetition. During the process of reminiscence both sad and happy memories are shared. The sharing of both should be encouraged. The nurse should avoid probing or pushing for details. The elder should be allowed to share informally and spontaneously.

8. B. Ego Integrity versus Despair is the final stage of Erikson’s psychosocial development. An indication of despair or self-disgust is manifested by the elder believing life has been too short and futile or that they want a chance to redo life. Statement B is consistent with despair. Signs of ego integrity are manifested by statements or tasks that bring together all the previous phases of the life cycle. Manifestations of successful ego integrity mastery include activities such as volunteering at the library (the elder believes they still have something to offer), continued learning (those in ego integrity remain creative), and assisting others (helping people learn to read is still contributing to society).

9. B. Oligohydramnios occurs when the amount of amniotic fluid is severely reduced. This would result in less than expected growth in the uterus, a fetus that is surrounded by so little amniotic fluid that it is easily palpated and outlined, and the fetus will not be palpable when the examiner does a vaginal exam and pushes against the cervix (ballottement).

10. D. Fetal heartbeat can be detected with Doppler as early as 10-12 weeks of pregnancy and is considered a positive or diagnostic sign of pregnancy. Amennorrhea, the absence of menses, is considered a presumptive sign of pregnancy. It is a more helpful sign when more than one cycle has been missed. Uterine soufflé, the sound heard on auscultation over the uterus that is caused by blood flow through the placenta, can also be caused by other conditions such as ovarian tumors or uterine myomas. It is considered a probable sign of pregnancy. A positive pregnancy test is based on the detection of Human Chorionic Gonadotropin. It is present during pregnancy, but there are other conditions that can cause it to be elevated so it is considered a probable sign of pregnancy.

11. C. By 20 weeks gestation the fetus is approximately 10 cm long or 7 ½ inches. Fetal lungs do not begin the movements of respiration until 24 weeks. Because oxygen is provided through the placenta, the function of the lungs for breathing does not occur until birth. The fetus can open its eyes at 28 weeks gestation. Fingernails begin to grow at 10 weeks gestation but are not complete until 38 weeks.

12. A. The first self-care measure to suggest is to practice frequent dorsi-flexion of the feet. If this is done, it would provide relief for two of the three symptoms the woman is experiencing: ankle edema and leg cramps

13. D. Newborns and young infants enjoy looking at themselves in the mirror. The human face is pleasing to them. Nurses must instruct parents to buy unbreakable mirrors to prevent injury. A jack-in-the-box may be fun for the parents, but a newborn does not have the capacity to turn the handle and make it work. This is too advanced a toy for a newborn

14. A. Finger foods are just now being introduced into the infant’s diet. Providing finger foods with different textures is a natural way to promote tactile stimulation. All of the remaining answers will provide tactile stimulation, but the question wants to know what to add.

15. D. The order of the physical exam should be adjusted to accommodate the developmental age of the child and the response of the child to being examined. Since the child is quiet and distracted with the chew toy, the nurse should be able to get a good listen to the heart and lungs without the child crying or squirming.

16. D. The Babinski sign is positive in children 12 months of age and younger. A 16-month-old with a positive Babinski would be cause for concern and require further evaluation. A positive Babinski is normal for a 4, 8, and 12-month-old child and not a cause for follow-up.

17. C. After the first trimester the pregnant woman should avoid exercising in the supping position. This is associated with decreased cardiac output. As a general rule, pregnant women should not engage in exercise that causes their heart rate to exceed a maximum of 140 beats per minute. Per the American College of Obstetricians and Gynecologists, pregnant women should not exercise to the point of fatigue or exhaustion. Hyperthermia may have teratogenic effects on the fetus so pregnant women should avoid hot tubs and saunas.

18. B. Because of the pressure placed on the vena cava by an enlarging uterus, a pillow should be placed under the right hip of the woman if she is lying on her back during intercourse. This will displace the uterus off the vena cava.

19. D. In addition to nursing diagnoses applicable to all pregnant women, the pregnant couple over the age of 35 may have additional concerns about the well-being of their baby as it relates to Down syndrome or other genetic disorders. Most couples over the age of 35 are more financially secure and have fewer concerns related to the cost of a birth. Couples over the age of 35 may have experienced infertility problems, births many years before, or have had problem births.

20. A. The combination of results presented in this situation may be the result of a fetus with Down syndrome. A neural tube defect can be detected with MSAFP but once the defect has occurred an increase in folic acid will not change it. Taking folic acid before becoming pregnant and continuing through the pregnancy can be beneficial to prevent neural tube defects. The physician needs to be notified of the results and the nurse could anticipate referral for an amniocentesis.

21. B. The Denver II is a screening test, not diagnostic. The results indicate what tasks the child was able to perform the day of the test only. It is not an intelligence test so no IQ score is obtained, it does not measure development. The word measure implies a diagnostic result. The test does not determine whether a child’s development is not normal. It screens only. If a child has a result other than normal that child either needs to be rescreened or evaluated by a developmental specialist to determine if the development is normal or not.

22. B. Most children walk between 11 and 15 months of age. To tell the parents that children walk by 12 months of age causes them concern needlessly because their child would actually have until 15 months of age before the nurse would be concerned. All children 18 and 24 months of age should be walking for some time.

23. C. Industry versus inferiority is the developmental stage of school age children. Trust versus mistrust is the developmental stage of infancy. Initiative versus guilt is the developmental stage of preschoolers, and autonomy versus shame and doubt is the developmental stage of toddlers.

24. B. Research has shown that sleeping with adults can contribute to sudden infant death syndrome. The mechanism is believed to be the rebreathing of carbon dioxide as the sleeping child snuggles against the parent. Increased attention during the day will not stop a child from wanting to sleep with their parent. In some cultures it is the norm for children to sleep with their parents. Some occasions provide reasons a parent might want the child to sleep with them, such as illness, nightmares, or bedroom space. Unless parents want this to become a habit, they will have to take measures to be sure it is only for the duration of the circumstance

25. D. Beauticians are excellent referral sources for the care and styling of wigs. They are able to show the client how to use combs, clips, and otherwise style and care for the wig. Clients should purchase and begin wearing their wigs before all their hair falls out. This will give them and others a chance to figure out how they want to style it.

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