health assessment practice questions nursing

Correct Answer: B

Rationale: The correct answer is B: Lyme disease. The presentation of a red circular rash with central clearing, known as erythema migrans, following a hiking trip in the summer is highly indicative of Lyme disease. The specific distribution of the rash across the midriff and behind the knees aligns with typical areas where the rash appears in Lyme disease cases. This rash is a hallmark sign of early Lyme disease caused by the bacterium Borrelia burgdorferi transmitted through the bite of an infected tick. Other answer choices are incorrect because rubeola presents with a different rash pattern, an allergy to mosquito bites would not typically present in this manner, and Rocky Mountain spotted fever typically presents with a different rash appearance and distribution.

Correct Answer: C

Rationale: The correct answer is C because the normal eardrum of a newborn can appear thick and opaque due to the presence of vernix or desquamated epithelium. Immobility of the drum (Choice A) is not a normal finding in a newborn and could indicate a problem. An "injected" membrane (Choice B) would suggest inflammation or infection, not necessarily infection. The appearance of the membrane in a newborn is not identical to that of an adult (Choice D) as it may have a different color, thickness, or opacity due to developmental differences.

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: B

Rationale: The correct answer is B: When the patient first noticed the lesion. This information is crucial for determining the duration of the ulceration, aiding in diagnosing potential causes like trauma or infections. Nutritional status (Choice A) may not be directly related to the specific lesion. Whether the patient has had a recent cold (Choice C) is less relevant unless there are other symptoms present. Exposure to sick animals (Choice D) is not pertinent to the mouth ulceration. Therefore, obtaining information on when the patient first noticed the lesion is the most important for proper assessment and treatment planning.

Correct Answer: A

Rationale: The correct answer is A: tinea capitis. Tinea capitis is a fungal infection of the scalp that can cause hair loss, scaling, and breakage of hair. In this case, the patient's symptoms of hair loss, patchy hair breakage, and scaling on the scalp are consistent with tinea capitis. The nurse should suspect tinea capitis based on the presentation of these specific symptoms in the patient. Summary: - B: tinea corporis is a fungal infection of the skin, not the scalp, so it is not the most likely cause of the patient's symptoms. - C: toxic alopecia refers to hair loss due to exposure to toxins, which is unlikely in this case based on the symptoms described. - D: seborrheic dermatitis is a common skin condition that causes redness, scaly patches, and dandruff on the scalp, but it does not typically cause hair loss in the same way as tinea capitis