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: A

Rationale: The dry mucosa and deep fissures in the tongue indicate dehydration in the patient. Dehydration causes decreased saliva production, leading to dry mouth and tongue fissures. This is a common symptom of dehydration. The lack of moisture in the oral cavity can result in these physical signs. The other choices are incorrect because irritation by gastric juices typically presents with other symptoms, a normal oral condition would not show these specific findings, and side effects of nausea medication would not directly cause dry mucosa and deep fissures in the tongue. Therefore, the correct answer is A: dehydration.

Correct Answer: B

Rationale: The correct answer is B: know that these are scars caused from frequent ear infections. The presence of dense white patches on the tympanic membrane in a patient with a history of chronic ear infections indicates scarring from previous infections. This is a common finding in individuals who have experienced recurrent middle ear infections. The other choices are incorrect because: A) Fungal infections typically present with different characteristics such as discoloration or debris in the ear canal, not dense white patches on the tympanic membrane. C) Blood in the middle ear would manifest as redness or hemorrhage, not white patches. D) While scarring may affect hearing, the description of the tympanic membrane in this case does not suggest any immediate concern for hearing loss.

Correct Answer: C

Rationale: The correct answer is C because the normal eardrum of a newborn can appear thick and opaque due to the presence of vernix or desquamated epithelium. Immobility of the drum (Choice A) is not a normal finding in a newborn and could indicate a problem. An "injected" membrane (Choice B) would suggest inflammation or infection, not necessarily infection. The appearance of the membrane in a newborn is not identical to that of an adult (Choice D) as it may have a different color, thickness, or opacity due to developmental differences.

Correct Answer: D

Rationale: The correct answer is D because tracheal shift due to thyroid enlargement occurs when the thyroid gland enlarges and displaces the trachea to the opposite side. This is a common clinical finding in conditions like a goiter. Other choices are incorrect because: A is incorrect as tracheal shift is not related to systole; B is incorrect as tracheal shift is typically caused by a mass pushing the trachea; C is incorrect as pleural adhesions don't typically cause tracheal shift.