nclex practice questions 2023 health assessment

Correct Answer: D

Rationale: The correct answer is D: "Have you noticed any dryness in your mouth?" This question is important as dryness in the mouth can be a side effect of certain medications used to manage hypertension and chronic lung disease. Dry mouth can lead to oral health issues and impact the patient's overall well-being. A: "Do you use a fluoride supplement?" is not directly relevant to the patient's medical history of hypertension and lung disease. B: "Have you had tonsillitis in the last year?" is not as crucial as dry mouth in relation to managing hypertension and lung disease. C: "At what age did you get your first tooth?" is not pertinent to the current medical conditions and management of hypertension and lung disease. In summary, the question about dryness in the mouth is the most relevant as it pertains to potential medication side effects and oral health implications for the patient with hypertension and chronic lung disease.

Correct Answer: D

Rationale: The correct answer is D. In an acute infection, such as streptococcal pharyngitis, the tonsils may exhibit yellowish exudates due to bacterial pus formation. This is consistent with the presence of inflammation and infection. Choices A, B, and C describe varying degrees of tonsillar enlargement and white debris, which could be present in different conditions but are not as specific to acute infection. Therefore, the presence of yellowish exudates on the tonsils is the key indicator of an acute bacterial infection like strep throat.

Correct Answer: C

Rationale: Step-by-step rationale for why choice C (CN VII) is correct: 1. Palpebral fissures are controlled by muscles innervated by CN VII (facial nerve). 2. Damage to CN VII can result in facial asymmetry, affecting palpebral fissures. 3. CN III (choice A) controls eye movement, not palpebral fissures. 4. CN V (choice B) controls facial sensation, not palpebral fissures. 5. CN VIII (choice D) controls hearing and balance, not palpebral fissures. Summary: Choice C is correct as damage to CN VII affects palpebral fissures due to facial muscle innervation. Choices A, B, and D are incorrect as they do not control the muscles responsible for palpebral fissures.

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: D

Rationale: The correct answer is D. Performing the otoscopic examination at the end of the assessment is the best approach for a 3-year-old with a suspected ear infection. This allows the child to become familiar with the nurse and the environment, reducing anxiety and increasing cooperation. It also prevents the child from becoming upset early in the examination, making it easier to complete the assessment. Choice A is incorrect because omitting the otoscopic exam based on the presence of a fever could lead to a missed diagnosis. Choice B is incorrect as pulling the ear up and back before inserting the speculum is not recommended as it may cause discomfort and increase resistance from the child. Choice C is incorrect as having the mother leave the room may increase the child's anxiety and make the examination more challenging.