nclex practice questions 2023 health assessment

Correct Answer: B

Rationale: The bright cherry-red coloring in a semiconscious woman found on the floor in her kitchen indicates carbon monoxide poisoning. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen, leading to tissue hypoxia and the characteristic cherry-red coloration. Polycythemia would result in a purplish-red color, carotenemia in a yellow-orange hue, and uremia in a pale or yellowish complexion. Therefore, the correct answer is B, as it aligns with the clinical presentation and pathophysiology of carbon monoxide poisoning.

Correct Answer: C

Rationale: The correct answer is C: The purpose of cerumen is to protect and lubricate the ear. Cerumen, commonly known as earwax, acts as a natural barrier to prevent dust, debris, and microorganisms from entering the ear canal. It also helps to lubricate the skin in the ear canal and prevent dryness and itching. Choice A is incorrect because sticky, honey-colored cerumen is not necessarily a sign of infection; it can occur due to various factors. Choice B is incorrect as the presence of cerumen does not solely indicate poor hygiene; everyone produces earwax regardless of hygiene practices. Choice D is incorrect as cerumen can sometimes block the ear canal and impair sound transmission rather than aid it.

Correct Answer: B

Rationale: The correct answer is B: increased vascularity in the upper respiratory tract as a result of the pregnancy. During pregnancy, hormonal changes lead to increased blood flow in the body, including the nasal passages, causing them to become more sensitive and prone to bleeding. This explains why the woman is experiencing more nosebleeds. Incorrect Choices: A: coagulation problems in the patient - This is incorrect as pregnancy is associated with hypercoagulability rather than coagulation problems. C: increased susceptibility to colds and nasal irritation - While pregnancy can lower immunity, this does not directly cause nosebleeds. D: inappropriate use of nasal sprays - This is not relevant to the situation described and does not explain the increased nosebleeds due to pregnancy.

Correct Answer: D

Rationale: The correct answer is D because the movement of extraocular muscles is primarily controlled by cranial nerves III, IV, and VI. CN III controls most of the eye movements, CN IV controls the superior oblique muscle, and CN VI controls the lateral rectus muscle. These nerves work together to coordinate eye movements in all directions. Choices A and B are incorrect because age or cataracts do not directly impact the stimulation of extraocular muscles. Choice C is incorrect as CNs I and II are not involved in controlling extraocular muscle movement.

Correct Answer: A

Rationale: The correct answer is A: Heart failure. In this case, the most likely cause of the bilateral pitting edema in the lower legs is heart failure. The pitting edema along with the history of hypertension and coronary artery disease suggests fluid overload due to the heart's inability to pump effectively. The normal skin color, absence of redness or tenderness, and strong peripheral pulses indicate that the edema is not caused by venous thrombosis, local inflammation, or blockage of lymphatic drainage. In heart failure, fluid can accumulate in the lower extremities due to the heart's reduced ability to pump blood efficiently, leading to increased pressure in the veins and subsequent fluid leakage into the surrounding tissues.