nclex physical and health assessment questions

Questions 46

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nclex physical and health assessment questions Questions

Question 1 of 5

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN _____ and starts the examination by:

Correct Answer: B

Rationale: The correct answer is B (XI; asking the patient to shrug her shoulders against resistance). This is the correct choice because the nurse suspects damage to the spinal accessory nerve (CN XI), which innervates the trapezius and sternocleidomastoid muscles. Asking the patient to shrug her shoulders against resistance tests the function of the trapezius muscle, which is innervated by CN XI. This examination helps to assess the integrity of the nerve and its ability to innervate the muscle. Palpating the anterior and posterior triangles (choice A) is not specific to CN XI function. Percussing the sternomastoid and submandibular neck muscles (choice C) is related to CN XII, not CN XI. Assessing for a positive Romberg's sign (choice D) is not relevant to testing the function of CN XI.

Question 2 of 5

Which of the following is the best way to palpate the lymph nodes in the neck?

Correct Answer: D

Rationale: The correct answer is D because using the index and middle fingers to palpate with gentle pressure in a rotating pattern allows for a thorough examination of the lymph nodes without causing discomfort or injury. This method helps to assess the size, shape, consistency, and tenderness of the nodes accurately. It also enables the examiner to detect any abnormalities such as enlargement or tenderness. A is incorrect as using strong pressure can be painful and lead to inaccurate assessment. B is incorrect as strong pressure can be harmful and may not provide the necessary sensitivity to detect abnormalities. C is incorrect as pinching each node can be uncomfortable and may not allow for a systematic examination of the lymph nodes.

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

A 70-year-old patient reports to the nurse that he is having trouble hearing, especially when he is in large groups. He says he"can't always tell where the sound is coming from" and the words often sound"mixed up." What might the nurse suspect as the cause for this?

Correct Answer: C

Rationale: The correct answer is C: Degeneration of nerves in the inner ear. This is likely the cause of the patient's hearing difficulties, as age-related degeneration of nerves in the inner ear can lead to difficulty distinguishing sounds and determining their direction. Atrophy of the apocrine glands (Choice A) and cilia becoming coarse and stiff (Choice B) are not related to hearing loss. Scarring of the tympanic membrane (Choice D) would affect sound conduction but not the perception of sound direction and clarity.

Question 5 of 5

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and a purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:

Correct Answer: C

Rationale: Rationale: The patient's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, pain in cheeks and teeth, and pain upon palpation all point towards maxillary sinusitis. The maxillary sinuses are located in the cheek area, and infection can lead to the described symptoms. Frontal sinusitis typically presents with forehead pain, and nasal polyps would not cause the specific symptoms mentioned. Posterior epistaxis involves bleeding from the back of the nose and is not consistent with the patient's symptoms. Therefore, the correct answer is C: maxillary sinusitis.

Similar Questions

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and a purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:
The nurse is palpating the sinus areas. If they are normal, which of the following would the patient report?
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How would the nurse proceed?
The mother of a newborn asks the nurse when her baby's eyesight will be fully developed. The nurse should say:
The nurse is performing an assessment on a 7-year-old child who has the following symptoms: chronic watery eyes, sneezing, and clear nasal drainage. The nurse notes the presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids. These findings are characteristic of:

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