nclex practice questions 2023 health assessment

Correct Answer: A

Rationale: The correct answer is A because fixating on an object at 2 weeks is within the expected developmental range. Infants typically develop the ability to follow objects later on. Choice B is incorrect as absence of following light doesn't indicate blindness. Choice C is unnecessary and premature. Choice D is incorrect as the ability to follow objects typically develops around 6-8 weeks.

Correct Answer: C

Rationale: The correct answer is C because lymph nodes are accessible for examination in the head and neck, arms, breasts, and axillae. Lymph nodes are present in these areas where they can be easily palpated and assessed for any signs of inflammation or abnormalities. The other choices are incorrect because they do not include all the areas where lymph nodes are accessible for examination. Choice A does not include the axillae, which is a crucial area for examining lymph nodes in the arms. Choice B does not include the axillae and breasts. Choice D does not include the breasts, which are important areas for lymph node examination in cases of breast cancer or other breast-related conditions.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Head control typically develops around 4 months, so it is normal for a 2-month-old to lack this skill. 2. Reassuring the mother that her baby is within the normal developmental range is important for reducing parental anxiety. 3. Avoiding overly alarming responses helps maintain trust and open communication with the parent. Summary: - Choice B is incorrect as it does not address the mother's concern and may come across as dismissive. - Choice C is incorrect as it may unnecessarily worry the mother and lead to undue stress. - Choice D is incorrect as it introduces a serious and unlikely scenario without evidence at this stage of development.

Correct Answer: D

Rationale: The correct answer is D because dry, flaky cerumen can indicate a change in cilia in the ear canal, potentially leading to conductive hearing loss. This warrants further assessment by the nurse to ensure the patient's aural health is not compromised. A: Eczema lesions typically present differently and are not directly related to dry cerumen. B: While hygiene can contribute to cerumen buildup, dry, flaky cerumen alone does not necessarily indicate poor hygiene. C: Dry, flaky cerumen is not considered a normal finding in a healthy ear and should prompt further evaluation.

Correct Answer: B

Rationale: The correct answer is B: parotid gland. The parotid gland is located in front of the ear lobe, and swelling below the angle of the jaw is a common sign of parotid gland inflammation. The tenderness and increasing size of the spot also point towards a parotid gland issue. The other choices, such as thyroid gland (A), occipital lymph node (C), and submental lymph node (D), are incorrect as they are not typically associated with the specific symptoms described by the patient. It is essential to consider the location and function of each structure to arrive at the correct diagnosis.