nclex physical and health assessment questions

Correct Answer: C

Rationale: The correct answer is C because it demonstrates cultural sensitivity and respect for the patient's comfort. Placing the nurse's thumbs on either side of the trachea and tilting the patient's head forward is a non-threatening and non-invasive approach to examining the thyroid. This position allows the nurse to assess the thyroid gland without causing discomfort or intimidation to the patient. Choice A is incorrect because having the nurse's hands placed firmly around the neck from behind may be perceived as invasive and threatening to the patient. Choice B is incorrect because having the nurse's thumbs on the patient's neck with eyes averted toward the ceiling may come across as awkward and unprofessional. Choice D is incorrect because tilting the patient's head backward can cause discomfort and may not be culturally sensitive as it can be perceived as invasive.

Correct Answer: D

Rationale: The correct answer is D: frenulum. The frenulum is a small fold of tissue that connects the tongue to the floor of the mouth. It helps to limit the movement of the tongue, preventing excessive movement that could lead to injury. The uvula (A) is a soft tissue dangling at the back of the throat, the palate (B) is the roof of the mouth, and papillae (C) are small raised structures on the tongue's surface. These structures are not involved in connecting the tongue to the floor of the mouth.

Correct Answer: A

Rationale: The correct answer is A: allergies. The symptoms described such as chronic watery eyes, sneezing, and clear nasal drainage are classic signs of allergies. The presence of a transverse line across the bridge of the nose, dark blue shadows under the eyes, and a double crease on the lower eyelids are typical physical exam findings in children with allergic rhinitis. These signs are known as Dennie-Morgan lines, allergic shiners, and allergic crease respectively. Allergies are the most likely cause based on the symptoms and physical exam findings. Sinus infection (choice B) typically presents with purulent nasal discharge and facial pain. Nasal congestion (choice C) usually involves nasal stuffiness and may not present with the specific eye findings mentioned. An upper respiratory infection (choice D) may present with fever, cough, and nasal discharge, but the eye findings described are not characteristic of an upper respiratory infection.

Correct Answer: C

Rationale: The correct answer is C: In an individual who is severely dehydrated. Decreased skin turgor is a clinical sign of dehydration, indicating loss of skin elasticity due to fluid loss. Severe dehydration leads to decreased skin turgor as the skin loses its ability to recoil when pinched. In cases of severe obesity (choice A), skin turgor is usually normal or increased due to excess adipose tissue. During childhood growth spurts (choice B), skin turgor is typically unaffected. Connective tissue disorders like scleroderma (choice D) can lead to changes in skin texture and appearance, but not necessarily decreased skin turgor.

Correct Answer: B

Rationale: The correct answer is B: cluster headaches. Cluster headaches are characterized by excruciating pain on one side of the head, often around the eye, forehead, and cheek. They occur once or twice each day and last for a relatively short duration of 30 minutes to 2 hours. This pattern of symptoms aligns with the typical presentation of cluster headaches. Incorrect Choices: A: Hypertension is unlikely to present with such specific unilateral head pain patterns and timing. C: Tension headaches typically present with more diffuse, mild to moderate pain and are not typically associated with eye, forehead, or cheek pain. D: Migraine headaches usually last longer than 2 hours and are commonly associated with other symptoms such as nausea, vomiting, and sensitivity to light and sound.