Pass the NCLEX NCLEX Certification NCLEX-PN Questions and answers with CertsForce

Teaching the client and family about progression of the disease includes explaining when symptoms can

be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no

permanent disruption in physical appearance will occur that could negatively affect body image. Clients with

Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions

and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image.

The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health

Promotion and Maintenance

Mammography is used to detect tumors or cysts in the breasts, not the other conditions.Reduction of Risk

Potential

Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of

stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or

other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats

can be relieved by hormone replacement therapy.Health Promotion and Maintenance

Of the nursing diagnoses listed, the client’s statement most represents Body Image Disturbance because it

directly refers to loss of the function of having a child. Nothing in the statement indicates that the client is at

risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the

statement does not reflect a disruption of the parent’s role. Powerlessness could be an appropriate nursing

diagnosis if the client described feeling powerless about the infertility.Health Promotion and Maintenance

A urologist consult is appropriate for a client with visible blood at the urethral meatus and suspected trauma.

Choices 1 and 2 are contraindicated. A urinalysis might be ordered by the physician, but the question does not

provide enough information to make Choice 3 the correct answer.Physiological Adaptation

The goals of palliative care include choices 1, 2, and 4. Choice 3 is not part of palliative care. All aspects of

medical, emotional, social, and spiritual needs of the dying client should be focused on until the end of life.Basic

Care and Comfort

The client with Parkinson’s disease can develop a shuffling gait and rigidity, causing impaired physical

mobility. The other diagnoses do not necessarily relate to a client with Parkinson’s disease.Reduction of Risk

Potential

The kidneys of a client in renal failure produce no erythropoietin, a hormone necessary for RBC production.

Erythropoietin can be given as replacement, but the client needs adequate iron, folate, and B12 to increase the

effectiveness of EPO. Choice 2 is not necessary for RBC production and can increase uremia. Choices 3 and 4

are not necessary for RBC production.Physiological Adaptation

Morton’s neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay

terms as abunion.Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation

of, or pain in, the arch of the foot.Basic Care and Comfort

Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants

interfere with mammography.Reduction of Risk Potential

Pathologic fractures are not common to the disease process. Its treatment through osteoporosis is a potential

complication of steroid use. Hodgkin’s disease most commonly affects young adults (males), is spread through

lymphatic channels to contiguous nodes, and also might spread via the hematogenous route to extradal sites (GI,

bone marrow, skin, and other organs). A working staging classification is performed for clinical use and care.

Physiological Adaptation

Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases.

The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the

world’s population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine

childhood immunization. They have not, however, been eradicated, so children need to be immunized against

these diseases.Physiological Adaptation

There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing

actions include asking the child to explain what each family member is doing, encouraging him or her to tell as

much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in

the drawing, noting facial expressions of family members and noting if they are facing each other or turned away.

Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting

themes to the child.Health Promotion and Maintenance

Huntington’s chorea is characterized by writhing, twisting movements of the face and limbs. The remaining

options are neurological disorders that do not have such movements as part of their disease process.Reduction of

Risk Potential

The small intestine has a primary function of absorption. The remaining digestive organs have other primary

functions.Physiological Adaptation