health assessment practice questions nursing

Correct Answer: C

Rationale: The correct answer is C because purpura is characterized by the presence of confluent and extensive patches of petechiae and ecchymoses. Petechiae are small, pinpoint hemorrhages less than 2mm in size, and ecchymoses are larger bruises. This presentation is indicative of a more severe underlying condition, such as a bleeding disorder or vasculitis. Choice A is incorrect as it describes spider veins or telangiectasias, not purpura. Choice B describes a birthmark, not purpura. Choice D is incorrect as it describes petechiae, not purpura, which involves larger areas of bleeding.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): 1. Immediate intervention is crucial as the newborn needs clear airways for breathing. 2. Inability to suction the nares can lead to respiratory distress and compromise the infant's oxygenation. 3. Waiting or attempting again may delay necessary actions, risking the baby's health. 4. Physician's assistance may be needed, but recognizing the urgency is the nurse's responsibility to ensure timely care. Summary of Incorrect Choices: A. Attempting to suction again with a bulb syringe may not resolve the issue and delay necessary intervention. B. Waiting for the infant to stop crying is not ideal as it may prolong the risk of respiratory distress. D. While physician assistance may be necessary, immediate recognition of the critical situation is the nurse's primary responsibility.

Correct Answer: C

Rationale: The correct answer is C: the presence of shadows, which may indicate glaucoma. When a light is directed across the iris from the temporal side, it helps in evaluating the presence of shadows in the anterior chamber angle, which can suggest a narrow or closed angle glaucoma. This technique is known as transillumination test and is important in detecting potential glaucoma cases. A: Drainage from dacryocystitis is incorrect as it is typically assessed by pressing on the lacrimal sac area to observe for discharge. B: Conjunctivitis over the iris is incorrect as conjunctivitis is an inflammation of the conjunctiva, not the iris. D: A scattered light reflex indicative of cataracts is incorrect as cataracts cause clouding of the lens, not scattering of light across the iris.

Correct Answer: C

Rationale: The correct answer is C: Spoon nails. In iron-deficiency anemia, the nails may develop a concave or spoon-like shape (koilonychia). This is due to the decreased oxygen supply to the nail bed. The characteristic spoon nails are indicative of severe iron deficiency. Splinter hemorrhages (choice A) are small areas of bleeding under the nails and are more commonly associated with conditions like endocarditis. Paronychia (choice B) is an infection around the nail, not specific to anemia. Beau's lines (choice D) are horizontal depressions in the nails, typically seen after a period of severe illness or stress, rather than specifically in iron-deficiency anemia.

Correct Answer: B

Rationale: The correct answer is B. When a patient experiences nosebleeds, the best way to stop it is by sitting straight with the head tilted slightly forward and pinching the nose firmly for about 10-15 minutes. This position helps reduce blood flow to the nose and promotes clotting. It is important not to tilt the head back as it can lead to blood going down the throat and potentially causing choking or vomiting. Cold compresses can also be applied to help constrict blood vessels. Choices A, C, and D are incorrect as they do not follow the proper technique for managing nosebleeds and can potentially worsen the situation.