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: C

Rationale: The correct answer is C: "This is a fungal infection caused by all the antibiotics you've received." The black, hairy tongue is a known side effect of prolonged antibiotic use, which disrupts the balance of normal oral flora and predisposes to fungal overgrowth, specifically of the yeast Candida. Antibiotics can eliminate the competing bacteria that normally keep Candida in check. Therefore, the patient's symptoms are most likely due to a fungal infection related to antibiotic therapy, rather than a bacterial issue or temporary overgrowth of hair. Biopsy is not necessary as the condition is commonly seen in this context and can be managed with appropriate treatment for fungal overgrowth.

Correct Answer: D

Rationale: The correct answer is D because dry, flaky cerumen can indicate a change in cilia in the ear canal, potentially leading to conductive hearing loss. This warrants further assessment by the nurse to ensure the patient's aural health is not compromised. A: Eczema lesions typically present differently and are not directly related to dry cerumen. B: While hygiene can contribute to cerumen buildup, dry, flaky cerumen alone does not necessarily indicate poor hygiene. C: Dry, flaky cerumen is not considered a normal finding in a healthy ear and should prompt further evaluation.

Correct Answer: C

Rationale: Step 1: Dark skin may not show cyanosis well, making choice A less reliable. Step 2: Erythema refers to redness, which may not be easily visible in dark skin, making choice B less suitable. Step 3: Palpating for edema and increased warmth allows for a more reliable assessment of inflammation in dark skin, making choice C the correct answer. Step 4: Palpating for tenderness and ecchymosis may be useful but not specific to inflammation assessment in dark skin, making choice D less relevant.