health assessment practice questions nursing

Correct Answer: D

Rationale: The signs and symptoms - severe headache, high fever, and neck stiffness - in a young adult point towards meningeal inflammation. The combination of these symptoms is indicative of a potential infection or inflammation of the meninges, the protective membranes surrounding the brain and spinal cord. The presence of fever and neck stiffness, in addition to the severe headache, raises concern for meningitis, an infection of the meninges. This is a medical emergency that requires prompt evaluation and treatment. Other choices are incorrect because: A: Head injury usually presents with a history of trauma, which is not mentioned in the scenario. B: Cluster headaches typically do not present with fever and neck stiffness. C: Migraine headaches do not typically cause such high fever and neck stiffness.

Correct Answer: D

Rationale: The correct answer is D because tracheal shift due to thyroid enlargement occurs when the thyroid gland enlarges and displaces the trachea to the opposite side. This is a common clinical finding in conditions like a goiter. Other choices are incorrect because: A is incorrect as tracheal shift is not related to systole; B is incorrect as tracheal shift is typically caused by a mass pushing the trachea; C is incorrect as pleural adhesions don't typically cause tracheal shift.

Correct Answer: D

Rationale: The correct answer is D: Enlarged regional lymph nodes. In otitis externa, there may be regional lymphadenopathy due to inflammation and infection. Rhinorrhea (A) is associated with upper respiratory infections, not otitis externa. Periorbital edema (B) is seen in conditions like periorbital cellulitis. Pain over the maxillary sinuses (C) is indicative of sinusitis, not otitis externa.

Correct Answer: B

Rationale: The correct answer is B. When a patient experiences nosebleeds, the best way to stop it is by sitting straight with the head tilted slightly forward and pinching the nose firmly for about 10-15 minutes. This position helps reduce blood flow to the nose and promotes clotting. It is important not to tilt the head back as it can lead to blood going down the throat and potentially causing choking or vomiting. Cold compresses can also be applied to help constrict blood vessels. Choices A, C, and D are incorrect as they do not follow the proper technique for managing nosebleeds and can potentially worsen the situation.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): 1. Immediate intervention is crucial as the newborn needs clear airways for breathing. 2. Inability to suction the nares can lead to respiratory distress and compromise the infant's oxygenation. 3. Waiting or attempting again may delay necessary actions, risking the baby's health. 4. Physician's assistance may be needed, but recognizing the urgency is the nurse's responsibility to ensure timely care. Summary of Incorrect Choices: A. Attempting to suction again with a bulb syringe may not resolve the issue and delay necessary intervention. B. Waiting for the infant to stop crying is not ideal as it may prolong the risk of respiratory distress. D. While physician assistance may be necessary, immediate recognition of the critical situation is the nurse's primary responsibility.