nclex practice questions 2023 health assessment

Correct Answer: B

Rationale: The correct answer is B because rubella can indeed damage the organ of Corti in the fetus, which is responsible for hearing. During the first trimester, when the hearing structures are forming, any damage to the organ of Corti can result in impaired hearing for the infant. Choice A is incorrect because rubella can impact the fetus, including the organs responsible for hearing. Choice C is incorrect because rubella can be harmful to the fetus at any stage of pregnancy, not just the second trimester. Choice D is incorrect because CN VIII (the vestibulocochlear nerve) is not directly affected by rubella, rather it is the organ of Corti that is damaged.

Correct Answer: D

Rationale: The correct answer is D: "Have you noticed any dryness in your mouth?" This question is important as dryness in the mouth can be a side effect of certain medications used to manage hypertension and chronic lung disease. Dry mouth can lead to oral health issues and impact the patient's overall well-being. A: "Do you use a fluoride supplement?" is not directly relevant to the patient's medical history of hypertension and lung disease. B: "Have you had tonsillitis in the last year?" is not as crucial as dry mouth in relation to managing hypertension and lung disease. C: "At what age did you get your first tooth?" is not pertinent to the current medical conditions and management of hypertension and lung disease. In summary, the question about dryness in the mouth is the most relevant as it pertains to potential medication side effects and oral health implications for the patient with hypertension and chronic lung disease.

Correct Answer: A

Rationale: The correct answer is A: Red and bulging. In otitis media, the tympanic membrane becomes red and bulging due to inflammation and fluid accumulation. This is an early sign as it indicates increased pressure within the middle ear. Choice B (Hypomobility) is incorrect because it refers to decreased movement of the tympanic membrane, which is not specific to otitis media. Choice C (Retraction with landmarks clearly visible) is incorrect as it suggests the tympanic membrane is pulled inward, which is more indicative of otitis media with effusion rather than acute otitis media. Choice D (Flat, slightly pulled in at the center, and moves with insufflation) is incorrect as it describes a normal or retracted tympanic membrane rather than the characteristic red and bulging appearance seen in otitis media.

Correct Answer: C

Rationale: Step 1: The nurse notices an enlarged and thick skull, which are common signs of acromegaly. Step 2: Acromegaly results from excess growth hormone, leading to changes in facial features. Step 3: Coarse facial features such as enlarged nose, lips, and jaw are classic signs of acromegaly. Step 4: Therefore, assessing for coarse facial features is crucial in confirming acromegaly. Summary: A: Exophthalmos is associated with hyperthyroidism, not acromegaly. B: Bowed long bones are seen in conditions like rickets, not acromegaly. D: An acorn-shaped cranium is not a typical feature of acromegaly.

Correct Answer: D

Rationale: The correct answer is D: lichenification. Lichenification is the thickening and hardening of the skin due to chronic scratching or rubbing. In this case, the patient's continuous scratching has led to lichenification. The term "terrible itch" indicates a persistent and severe itching sensation, which aligns with the chronic scratching behavior. Choices A, B, and C are not correct because a keloid is an overgrowth of scar tissue, a fissure is a small cut or crack in the skin, and keratosis is the thickening of the outer layer of the skin. These conditions are not directly related to chronic scratching behavior.