health assessment practice questions

Questions 45

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health assessment practice questions Questions

Question 1 of 5

A patient has a normal pupillary light reflex. The nurse recognizes this to indicate that:

Correct Answer: D

Rationale: The correct answer is D because a normal pupillary light reflex involves the constriction of both pupils in response to bright light. This reflex is controlled by the autonomic nervous system, specifically the parasympathetic nervous system. When light is detected by the retina, signals are sent to the brain which then triggers the constriction of both pupils to reduce the amount of light entering the eye. Choices A, B, and C are incorrect because they do not accurately describe the pupillary light reflex. Vision convergence, light reflection, and focusing the image at the center of the pupil are not directly related to the pupillary light reflex.

Question 2 of 5

During an examination, the nurse finds that a patient's left temporal artery is more tortuous and feels hardened and tender compared with the right temporal artery. What condition does the nurse suspect?

Correct Answer: C

Rationale: The correct answer is C: Temporal arteritis. Temporal arteritis is characterized by inflammation of the temporal arteries, leading to symptoms such as tenderness, hardness, and tortuosity. The left temporal artery being more affected than the right is a common presentation. Crepitation (choice A) refers to a crackling sound or sensation, typically associated with bone or joint abnormalities, not arterial inflammation. Mastoiditis (choice B) is an infection of the mastoid bone behind the ear, not related to temporal arteries. Bell's palsy (choice D) is a condition affecting facial nerves, not arteries.

Question 3 of 5

The nurse notices that the mother of a 2-year-old boy brings him to the clinic quite frequently for various injuries and suspects there may be some child abuse involved. The nurse should inspect the young child for:

Correct Answer: C

Rationale: The correct answer is C: bruising on the buccal mucosa or gums. This is the most relevant choice as it is a common sign of physical abuse in children. Bruising in unusual places or patterns, such as the mouth, should raise suspicion. Swollen, red tonsils (A) are more likely related to infection rather than abuse. Ulcerations on the hard palate (B) can also be due to various non-abuse related reasons. Small yellow papules along the hard palate (D) are typically harmless and not indicative of abuse. It is crucial for the nurse to recognize signs of potential abuse and take appropriate action to protect the child.

Question 4 of 5

During the examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that:

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. Enlargement of the thyroid gland during pregnancy is a normal finding due to hormonal changes. 2. The thyroid gland enlarges to meet the increased demands of thyroid hormone production. 3. This condition is known as gestational thyrotoxicosis and is usually benign. 4. No further testing is needed for thyroid cancer unless other concerning symptoms are present. Summary: A: Not relevant as iodine deficiency is not typically associated with thyroid enlargement in pregnancy. B: Incorrect as early signs of goitre would involve more pronounced symptoms than just slight enlargement. D: Unnecessary as thyroid cancer is not a common concern in this scenario of a slightly enlarged thyroid in the third trimester of pregnancy.

Question 5 of 5

During the assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. Which condition does the nurse suspect?

Correct Answer: B

Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.

Similar Questions

During the assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. Which condition does the nurse suspect?
The nurse is obtaining history for a 3-month-old infant. During the interview, the mother states,"I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
During examination of a 4-year-old Aboriginal child, the nurse notices that her uvula is partially split. Which of the following statements about this condition is accurate?
The papule on the nose of a 52-year-old woman has rounded, pearly borders and a central red ulcer. She tells the nurse that it has been present for several months and is slowly growing larger. Which of the following conditions does the nurse suspect?
The nurse is conducting an eye clinic at the day care centre. When examining a 2-year-old child, if"lazy eye" is suspected, the nurse would:

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