nclex physical and health assessment questions

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.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Whispering two-syllable words ensures a low volume, requiring the patient to focus on clarity. 2. Asking the patient to repeat tests their ability to hear and understand the whispered words accurately. 3. Whispering helps eliminate the influence of lip-reading, ensuring accurate assessment. Summary: A: Shielding the lips while speaking would hinder the patient's ability to hear clearly. C: Placing a finger in the ear would not be appropriate as it could affect the accuracy of the test. D: Standing at a specific distance does not ensure accurate assessment of hearing ability.

Correct Answer: C

Rationale: The correct answer is C: decreased ability to identify odors. As people age, their sense of smell tends to decline due to changes in the olfactory system. This is a common phenomenon in older adults and can impact their overall quality of life. The other choices are incorrect because hypertrophy of the gums (A) is not a typical finding in older adults, increased production of saliva (B) is not directly related to aging, and finer and less prominent nasal hair (D) is not a definitive characteristic of older age.

Correct Answer: D

Rationale: The correct answer is D. The "soft spot" on a baby's head, also known as the fontanelle, is a normal anatomical feature that allows for the growth and development of the baby's brain during the first year of life. It is a gap between the bones of the skull that eventually closes as the baby grows. Response A is incorrect because the fontanelle is not related to maternal dietary intake during pregnancy. Response B is incorrect as craniosynostosis is a condition where the sutures of the skull close prematurely, leading to abnormal head shape. Response C is incorrect as cretinism and congenital hypothyroidism are not typically associated with the fontanelle. Overall, the correct response, D, provides an accurate explanation of the normal function of the fontanelle in a newborn's development.

Correct Answer: D

Rationale: The correct answer is D, an ulceration with rolled edges on the side of the tongue, as it could indicate a possible malignancy such as oral cancer. The presence of rolled edges is concerning for malignancy due to the irregularity in shape and potential for rapid growth. This finding should be promptly investigated to rule out cancer. A: A painful vesicle inside the cheek for 2 days is likely a benign condition such as a canker sore. B: The presence of moist, nontender Stenson's ducts is a normal finding in the mouth. C: Stippled gingival margins that adhere snugly to the teeth could indicate a healthy gum tissue attachment. In summary, the other choices are less concerning as they are either benign or normal variations, while the presence of an ulceration with rolled edges raises significant suspicion for malignancy.