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NCLEX-RN
REVIEW
Health Promotion & Maintenance
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 Health
Promotion &
Maintenance
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 1. The nurse has been teaching adult clients about cardiac

risks when they visit the hypertension clinic. Which

evaluation data would best measure learning?

A) Performance on written tests

B) Responses to verbal questions

C) Completion of a mailed survey

D) Reported behavioral changes

1 D: Reported behavioral changes. If the client alters behaviors such as

smoking, drinking alcohol, and stress management, these suggest that

learning has occurred. Additionally, physical assessments and lab data may

confirm risk reduction.

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 2. The nurse is assessing a client who states her last menstrual period

was March 16, and she has missed one period. She reports episodes

of nausea and vomiting. Pregnancy is confirmed by a urine test. What

will the nurse calculate as the estimated date of delivery (EDD)?

A) April 8

B) January 15

C) February 11

D) December 23

2 D: December 23. Naegele’s rule

states: Add 7 days and subtract 3
months from the first day of the
last regular menstrual period to
calculate the estimated date of
d e l i v e r y.

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 3. The parents of a child who has suddenly been hospitalized

for an acute illness state that they should have taken the

child to the pediatrician earlier. Which approach by the nurse

is best when dealing with the parents' comments?

A) Focus on the child's needs and recovery

B) Explain the cause of the child's illness

C) Acknowledge that early care would have been better

D) Accept their feelings without judgment

3 D: Accept their feelings without judgment. Parents often

blame themselves for their child''s illness. Feeling helpless

and angry is normal and these feelings must be accepted.

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 4. When observing 4 year-old children playing in the hospital

playroom, what activity would the nurse expect to see the

children participating in?

A) Competitive board games with older children

B) Playing with their own toys along side with other children

C) Playing alone with hand held computer games

D) Playing cooperatively with other preschoolers

4 D: Playing cooperatively with other

preschoolers. Cooperative play is

typical of the late preschool period.

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 5. A 64 year-old client scheduled for surgery with a general anesthetic refuses

to remove a set of dentures prior to leaving the unit for the operating room.

What would be the most appropriate intervention by the nurse?

A) Explain to the client that the dentures must come out as they may get lost

or broken in operating room

B) Ask the client if there are second thoughts about having the procedure

C) Notify the anesthesia department and the surgeon of the client's refusal

D) Ask the client if the preference would be to remove the dentures in the

operating room receiving area

5 D: Ask the client if the preference would be to remove the dentures in

the operating room receiving area. 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.

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 6. When teaching a 10 year-old child about their impending heart

surgery, which form of explanation meets the developmental needs of

this age child?

A) Provide a verbal explanation just prior to the surgery

B) Provide the child with a booklet to read about the surgery

C) Introduce the child to another child who had heart surgery 3 days

ago

D) Explain the surgery using a model of the heart

6 D: Explain the surgery using a model of the heart. According to Piaget,

the school age child is in the concrete operations stage of cognitive

development. Using something concrete, like a model will help the child

understand the explanation of the heart surgery.

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 7. When screening children for scoliosis, at what time of

development would the nurse expect early signs to appear?

A) Prenatally on ultrasound

B) In early infancy

C) When the child begins to bear weight

D) During the preadolescent growth spurt

7 D: During the preadolescent growth spurt. Idiopathic scoliosis is seldom

apparent before 10 years of age and is most noticeable at the beginning of

the preadolescent growth spurt. It is more common in females than in

males.

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 8. A client is admitted to the hospital with a history of confusion. The

client has difficulty remembering recent events and becomes disoriented

when away from home. Which statement would provide the best reality

orientation for this client?

A) "Good morning. Do you remember where you are?"

B) "Hello. My name is Elaine Jones and I am your nurse for today."

C) "How are you today? Remember, you're in the hospital."

D) "Good morning. You’re in the hospital. I am your nurse Elaine Jones."

8 D: "Good morning. You’re in the hospital. I am your nurse Elaine Jones."

As cognitive ability declines, the nurse provides a calm, predictable

environment for the client. This response establishes time, location and the

caregiver’s name.

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9. The nurse is assessing a 4 month-old infant. Which

motor skill would the nurse anticipate finding?

A) Hold a rattle

B) Bang two blocks

C) Drink from a cup

D) Wave "bye-bye"

9 A: Hold a rattle. The age at which a

baby will develop the skill of grasping

a toy with help is 4 to 6 months.

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 10. An appropriate treatment goal for a client with

anxiety would be to

A) ventilate anxious feelings to the nurse

B) establish contact with reality

C) learn self-help techniques

D) become desensitized to past trauma

10 C: learn self-help techniques. Exploring alternative coping mechanisms

will decrease present anxiety to a manageable level. Assisting the client

to learn self-help techniques will assist in learning to cope with anxiety.

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 11. The family of a 6 year-old with a fractured femur asks the nurse if

the child's height will be affected by the injury. Which statement is

true concerning long bone fractures in children?

A) Growth problems will occur if the fracture involves the periosteum

B) Epiphyseal fractures often interrupt a child's normal growth pattern

C) Children usually heal very quickly, so growth problems are rare

D) Adequate blood supply to the bone prevents growth delay after

fractures

11 B: Epiphyseal fractures often interrupt a child''s normal growth pattern.

The epiphyseal plate in children is where active bone growth occurs. Damage

to this area may cause growth arrest in either longitudinal growth of the limb

or in progressive deformity if the plate is involved. An epiphyseal fracture is

serious because it can interrupt and alter growth.

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 12. While caring for a client, the nurse notes a pulsating

mass in the client's periumbilical area. Which of the following

assessments is appropriate for the nurse to perform?

A) Measure the length of the mass

B) Auscultate the mass

C) Percuss the mass

D) Palpate the mass

12 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.

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 13. While the nurse is administering medications to a client, the

client states "I do not want to take that medicine today." Which of

the following responses by the nurse would be best?

A) "That's OK, its all right to skip your medication now and then."

B) "I will have to call your doctor and report this."

C) "Is there a reason why you don't want to take your medicine?"

D) "Do you understand the consequences of refusing your prescribed

treatment?"

13 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.

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 14. The nurse is teaching the parents of a 3 month-old infant

about nutrition. What is the main source of fluids for an

infant until about 12 months of age?

A) Formula or breast milk

B) Dilute nonfat dry milk

C) Warmed fruit juice

D) Fluoridated tap water

14 A: Formula or breast milk. Formula or

breast milk are the perfect food and source

of nutrients and liquids up to 1 year of age.

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 15. A client states, "People think I’m no good, you know what I mean?"

Which of these responses would be most therapeutic?

A) "Well people often take their own feelings of inadequacy out on

others."

B) "I think you’re good. So you see, there’s one person who likes you."

C) "I’m not sure what you mean. Tell me a bit more about that."

D) "Let's discuss this to see the reasons you create this impression on

people."

15 C: "I’m not sure what you mean.

Te l l m e a b i t m o r e a b o u t t h a t . " T h i s
therapeutic communication technique
elicits more information, especially
when delivered in an open, non-
judgmental fashion.

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 16. When teaching effective stress management techniques to

a client 1 hour before surgery, which of the following should

the nurse recommend?

A) Biofeedback

B) Deep breathing

C) Distraction

D) Imagery

16 B: Deep breathing. Deep breathing is a reliable and

valid method for reducing stress, and can be taught

and reinforced in a short period pre-operatively.

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 17. The nurse is planning care for an 18 month-old child.

Which action should be included in the child's care?

A) Hold and cuddle the child frequently

B) Encourage the child to feed himself finger food

C) Allow the child to walk independently on the nursing unit

D) Engage the child in games with other children

17 B: Encourage the child to feed himself finger food. According to

Erikson, the toddler is in the stage of autonomy versus shame and doubt.

The nurse should encourage increasingly independent activities of daily

living that allow the toddler to assert his budding sense of control.

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 18. A client being treated for hypertension returns to the community clinic for

follow up. The client says, "I know these pills are important, but I just can't

take these water pills anymore. I drive a truck for a living, and I can't be

stopping every 20 minutes to go to the bathroom." Which of these is the best

nursing diagnosis?

A) Noncompliance related to medication side effects

B) Knowledge deficit related to misunderstanding of disease state

C) Defensive coping related to chronic illness

D) Altered health maintenance related to occupation

18 A: Noncompliance related to medication side effects. The client

kept his appointment, and stated he knew the pills were important.

He is unable to comply with the regimen due to side effects, not

because of a lack of knowledge about the disease process.

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 19. A client with congestive heart failure is newly admitted to home

health care. The nurse discovers that the client has not been following

the prescribed diet. What would be the most appropriate nursing action?

A) Discharge the client from home health care because of noncompliance

B) Notify the provider of the client's failure to follow prescribed diet

C) Discuss diet with the client to learn the reasons for not following the

diet

D) Make a referral to Meals-on-Wheels

19 C: Discuss diet with the client to learn the reasons for not following the diet. When new

problems are identified, it is important for the nurse to collect accurate assessment data.

Before reporting findings to the provider, it is best to have a complete understanding of

the client''s behavior and feelings as a basis for future teaching and intervention.

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 20. A partner is concerned because the client frequently daydreams about moving to

Arizona to get away from the pollution and crowding in southern California. The

nurse explains that

A) such fantasies can gratify unconscious wishes or prepare for anticipated future

events

B) detaching or dissociating in this way postpones painful feelings

C) converting or transferring a mental conflict to a physical symptom can lead to

conflict within the partnership

D) isolating the feelings in this way reduces conflict within the client and with others

20 A: such fantasies can gratify unconscious wishes or prepare for

anticipated future events. Fantasy is imagined events (daydreaming)

to express unconscious conflicts or gratify unconscious wishes.

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