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 a bruit in a 3-year-old child, especially over the temporal area, is not a normal finding and could indicate a serious underlying issue such as an arteriovenous malformation or other vascular abnormality. Stopping the examination and notifying the physician is crucial for further evaluation and management. A: Continuing the examination is not appropriate as the bruit should prompt further investigation. B: Checking again in 1 hour is unnecessary delay in addressing a potentially serious issue. C: Notifying the parents alone without medical intervention may delay necessary evaluation and treatment.

Correct Answer: D

Rationale: The correct answer is D: convergence of the axes of the eyes. During the accommodation response, the eyes converge to focus on a near object. This is necessary to maintain clear vision when looking at close objects. Dilation of the pupils (A) is not part of the accommodation response. A consensual light reflex (B) refers to both pupils constricting simultaneously in response to light, not specific to accommodation. Conjugate movement of the eyes (C) refers to both eyes moving together in the same direction, which is not the primary action during accommodation.

Correct Answer: B

Rationale: The correct answer is B: not palpable. In healthy adults, most lymph nodes are not palpable as they are typically small and not easily detectable through touch. This indicates normal lymphatic function and absence of significant inflammation or infection. Choices A, C, and D describe characteristics of abnormal lymph nodes, such as being shotty, large/firm/fixed, or rubbery/discrete/mobile, respectively, which are indicative of pathological conditions like infection, malignancy, or inflammation. Therefore, the absence of palpable lymph nodes in a healthy individual is the expected norm.

Correct Answer: D

Rationale: The correct answer is D because over-the-counter nasal sprays, especially those containing decongestants, can lead to rebound swelling when used for an extended period. Rebound swelling occurs when the nasal passages become more congested after the effects of the medication wear off. This can result in a cycle of dependency on the nasal spray to alleviate symptoms, leading to worsening congestion over time. It is important for the nurse to educate the patient about this potential risk and suggest alternative treatment options to address her allergies effectively without causing rebound swelling. Choices A, B, and C are incorrect because: A: Incorrect, as not all over-the-counter nasal sprays carry a risk of addiction. B: Incorrect, as switching to another brand may not address the underlying issue of rebound swelling. C: Incorrect, as continuous use of the nasal spray without addressing rebound swelling can exacerbate the problem.