health assessment practice questions nursing

Correct Answer: A

Rationale: The correct answer is A: At birth, the head is one fifth the total length. This is because newborns have relatively larger heads compared to their body size. This is known as cephalocaudal growth, where development starts from the head and progresses down the body. The head being one-fifth of the total length is a normal proportion in newborns. Choice B is incorrect because at birth, the chest circumference is usually greater than the head circumference. Choice C is incorrect as the head size reaches about 80% of its final size by age 2, not 3 years old. Choice D is incorrect because the closure of the anterior fontanelle at 2 months does not necessarily mean the head will appear proportionate to the body; it continues to grow in proportion to the body size.

Correct Answer: D

Rationale: The correct answer is D because it directly addresses the concern of a possible perforated eardrum by inquiring about the relationship between ear pain and discharge. This is crucial in assessing the severity of the condition. Choice A is incorrect as it focuses on subjective symptoms not specific to a perforated eardrum. Choice B is irrelevant as it doesn't pertain to the immediate concern. Choice C is also incorrect as it doesn't target the current issue of a potential perforated eardrum. Asking about ear pain and discharge helps determine the likelihood of a perforated eardrum and guides further assessment and care.

Correct Answer: A

Rationale: Visual accommodation refers to the ability of the eye to adjust focus when shifting gaze between objects at different distances. The correct answer is A, pupillary constriction when looking at a near object, as this is a key component of visual accommodation. When looking at a near object, the eye needs to adjust its focus by constricting the pupil to allow more depth of field and clearer vision. This process helps in bringing near objects into focus. Choices B, C, and D are incorrect: B: Pupillary dilation when looking at a far object is not related to visual accommodation, as the pupil dilates in low light conditions to allow more light to enter the eye. C: Changes in peripheral vision in response to light is not related to visual accommodation, as peripheral vision refers to the ability to see objects outside the direct line of sight. D: Involuntary blinking in the presence of bright light is a protective reflex to shield the eyes from excessive light and is not directly related to visual

Correct Answer: B

Rationale: The correct answer is B: Nothing, this is the appearance of normal tonsils. In a 30-year-old, tonsils commonly appear involuted, granular, and have deep crypts due to natural aging and exposure to infections. This is considered a normal variant and does not typically require further intervention. Referral to a specialist (Option A) is unnecessary as these findings are within the normal range. Continuing the assessment (Option C) may not yield significant abnormal findings related to the tonsils. Throat culture for strep (Option D) is not indicated unless there are specific symptoms or signs of infection.

Correct Answer: C

Rationale: The correct answer is C: the presence of shadows, which may indicate glaucoma. When a light is directed across the iris from the temporal side, it helps in evaluating the presence of shadows in the anterior chamber angle, which can suggest a narrow or closed angle glaucoma. This technique is known as transillumination test and is important in detecting potential glaucoma cases. A: Drainage from dacryocystitis is incorrect as it is typically assessed by pressing on the lacrimal sac area to observe for discharge. B: Conjunctivitis over the iris is incorrect as conjunctivitis is an inflammation of the conjunctiva, not the iris. D: A scattered light reflex indicative of cataracts is incorrect as cataracts cause clouding of the lens, not scattering of light across the iris.