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Test Prep NCLEX-PN Exam
National Council Licensure Examination(NCLEX-PN) (Page 15 )

Updated On: 30-Jan-2026
Page 15 of 204
PDF with 1015 Questions

After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?

  1. maintaining adequate tissue perfusion
  2. demonstrating behaviors that reduce fears
  3. restored body integrity
  4. remaining free of infection

Answer(s): C

Explanation:

A sense of restored body integrity is an expected outcome for interventions related to disturbed body image. Adequate tissue perfusion is an outcome for risk of injury and risk of infection, not disturbed body image.
Demonstrating behaviors that might reduce fears is an outcome for anxiety. Remaining free of infection is an outcome for risk of infection.



When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

  1. grief work facilitation
  2. vital signs monitoring
  3. medication administration: skin
  4. anxiety reduction

Answer(s): A

Explanation:

Grief work facilitation is a nursing intervention classification for disturbed body image in burn clients. The expected outcome is grief resolution.
Vital signs monitoring is a nursing intervention classification for deficient fluid volume in clients with major burns.
Medication administration: skin is a nursing intervention classification for impaired skin integrity for clients with major burns.
Anxiety reduction is a nursing intervention classification for anxiety experienced by clients with major burns.



When a client who is having trouble conceiving says to the nurse, “I have started taking ginseng,” the best response by the nurse is ______________.

  1. “No studies show that ginseng is effective for infertility.”
  2. “Some studies show that ginseng enhances in vitro sperm motility.”
  3. “Why don’t you try acupuncture instead. Many studies have shown it to be effective for infertility.”
  4. “It’s probably not going to hurt you, but it’s also probably not going to help. Let’s look at some other alternatives.”

Answer(s): B

Explanation:

Some studies have shown that ginseng and astragalus have enhanced in vitro sperm motility. Ginseng has long been used in traditional Chinese medicine to enhance male fertility. So, Choice “Some studies show that ginseng enhances in vitro sperm motility.” is correct and directly addresses the client’s comments.

Many times couples struggling with infertility turn to alternative therapies in desperation. They can be very expensive, and some are harmful. Ginseng should not interfere with any of the traditional fertility treatments and might help the couple feel empowered that they are also doing something on their own. Choice “No studies show that ginseng is effective for infertility.” is not true.
Choice “Why don’t you try acupuncture instead. Many studies have shown it to be effective for infertility.” introduces another alternative therapy. It is true that acupuncture is a traditional Chinese medical therapy and has been shown in several clinical studies to be effective in treating infertility in both women and men. The best response by the nurse should address the therapy the client states she is using.

Choice “It’s probably not going to hurt you, but it’s also probably not going to help. Let’s look at some other alternatives.” dismisses the client’s attempts to work through her issues and contribute to the solution. One concern is always that more traditional therapies might be ignored, and time might be lost to alternative therapies. But this response causes the client to perceive the nurse as unsupportive and inhibits further discussion and disclosure.



A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm.

The nurse correctly documents the finding as ______________.

  1. ferning capacity
  2. lack of ferning
  3. spinnbarkheit
  4. inhospitable

Answer(s): C

Explanation:

Spinnbarkheit is the correct terminology to identify the cervical mucus described. This type of mucus occurs at ovulation and its assessment is used to help couples determine the time they are most likely to conceive.
Ferning capacity or crystallization also increases as ovulation approaches. The only way that ferning can be identified is to place the cervical mucus on a microscope slide, let it air dry, and then examine it for a fern-type appearance.
Lack of ferning cannot be determined without microscopic examination. Inhospitable cervical mucus refers to mazelike patterns of mucoid strands in cervical mucus that prohibit sperm motility.
Other characteristics that make the mucus inhospitable relate to hormone levels, infection, and so on. These conditions cannot be determined by the description supplied in the question.



When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?

  1. Sex role identification begins in infancy.
  2. Sex role identification begins in the preschool years.
  3. Sex role identification begins during the school-age years.
  4. Sex role identification begins during early adolescence.

Answer(s): A

Explanation:

Sex role identification begins during infancy. Infants can identify body parts by the end of the first year.
Preschoolers frequently engage in masturbation and sex play with peers.
School-age children continue to gain awareness of their sexual identity. During this time, they might continue to masturbate and engage in sex play. They might add behaviors such as hugging and kissing members of the opposite sex.
Adolescent sex role identification is largely influenced by sexual maturation and trying out or assuming a sex role.



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