nclex physical and health assessment questions

Questions 46

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nclex physical and health assessment questions Questions

Question 1 of 5

A father brings his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been occurring at least every 2 hours. The nurse suspects dehydration. Where should the nurse test skin mobility and turgor in this infant?

Correct Answer: A

Rationale: The correct answer is A: Over the sternum. When testing for skin mobility and turgor in infants, the sternum is the best location. This area is less affected by factors like fat distribution and muscle tone, providing a more accurate assessment of dehydration. The skin should be gently pinched and released to observe how quickly it returns to its normal position - delayed return indicates dehydration. The other choices are incorrect because testing over the forehead, forearms, or abdomen may not provide an accurate assessment due to variations in fat distribution, muscle tone, or skin elasticity in those areas.

Question 2 of 5

The nurse is performing an eye assessment on an 80-year-old patient. Which of the following findings is considered abnormal?

Correct Answer: B

Rationale: The correct answer is B because unequal pupillary constriction in response to light is abnormal and may indicate nerve damage or neurological issues. A: Decrease in tear production is common with age. C: Arcus senilis is a normal age-related change. D: Loss of hair at the outer line of the eyebrows is also a common age-related change.

Question 3 of 5

The temporomandibular joint is just below the temporal artery and anterior to the:

Correct Answer: D

Rationale: The correct answer is D: mandible. The temporomandibular joint is located just below the temporal artery and it connects the mandible (lower jaw) to the temporal bone. This joint allows for movement of the jaw during actions like chewing and speaking. Choices A, B, and C are incorrect because the temporomandibular joint is not located near the hyoid bone (A), the vagus nerve (B), or the tragus of the ear (C). These structures are not directly associated with the temporomandibular joint's anatomical location and function.

Question 4 of 5

The nurse is conducting a hearing assessment using the Romberg test. The nurse is assessing for:

Correct Answer: D

Rationale: The Romberg test assesses the maintenance of standing balance by having the patient stand with feet together, arms at the sides, and eyes closed. If the patient sways or loses balance, it may indicate proprioceptive deficits. Conductive hearing loss (A) is related to sound transmission issues in the outer or middle ear, not balance. Lateralization of hearing (B) relates to distinguishing sound direction. Sensorineural loss (C) involves inner ear or auditory nerve damage, not balance. Therefore, the correct answer is D as the Romberg test specifically evaluates standing balance.

Question 5 of 5

While obtaining history for a 1-year-old from the mother, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states that"it makes a great pacifier." The best response by the nurse would be:

Correct Answer: D

Rationale: The correct answer is D: "Prolonged use of a bottle can increase the risk for tooth decay and ear infections." This response is the best because it addresses the potential consequences of prolonged bottle use, which include tooth decay and ear infections. It educates the mother on the risks associated with using a bottle as a pacifier for an extended period. Rationale: 1. Tooth decay: Prolonged exposure to sugary liquids in the bottle can lead to tooth decay, as the sugar feeds bacteria in the mouth. 2. Ear infections: Bottle-feeding while lying down can increase the risk of ear infections due to fluid entering the Eustachian tube. 3. Education: The response educates the mother on the specific risks associated with prolonged bottle use, promoting informed decision-making. 4. Health promotion: By highlighting the potential negative outcomes, the nurse is advocating for the baby's health and well-being. Incorrect Choices: A: "You're right, bottles make

Similar Questions

While obtaining history for a 1-year-old from the mother, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states that"it makes a great pacifier." The best response by the nurse would be:
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