health assessment practice questions

Correct Answer: B

Rationale: The correct answer is B: impetigo. The characteristics of moist, thin-roofed vesicles with a thin erythematous base are classic features of impetigo, a bacterial skin infection commonly seen in children. Impetigo is highly contagious and commonly affects the face and buttocks. The presence of blisters and scabs further supports the diagnosis of impetigo. Explanation of other choices: A: Eczema typically presents as dry, itchy patches of skin with redness and scaling. It does not usually manifest as vesicles or blisters. C: Herpes zoster, also known as shingles, presents as a painful rash with grouped vesicles on one side of the body along a nerve pathway. It is uncommon in children and usually affects older individuals. D: Diaper dermatitis is a common rash in infants due to prolonged skin exposure to urine and feces. It typically presents as redness, irritation, and possibly skin breakdown in the diaper

Correct Answer: C

Rationale: Step-by-step rationale: 1. Anisocoria is a condition where pupils are of unequal size. 2. It is typically caused by issues in the eye muscles or nerves controlling pupil size. 3. The nurse would expect to observe pupils of different sizes. 4. Dilated pupils (choice A) and excessive tearing (choice B) are not indicative of anisocoria. 5. An uneven curvature of the lens (choice D) does not directly relate to pupil size differences. Summary: Correct answer C is supported by the definition of anisocoria and its usual presentation. Choices A, B, and D are incorrect as they do not align with the characteristic feature of anisocoria.

Correct Answer: D

Rationale: The correct answer is D because a normal pupillary light reflex involves the constriction of both pupils in response to bright light. This reflex is controlled by the autonomic nervous system, specifically the parasympathetic nervous system. When light is detected by the retina, signals are sent to the brain which then triggers the constriction of both pupils to reduce the amount of light entering the eye. Choices A, B, and C are incorrect because they do not accurately describe the pupillary light reflex. Vision convergence, light reflection, and focusing the image at the center of the pupil are not directly related to the pupillary light reflex.

Correct Answer: A

Rationale: The correct answer is A: "Are you aware of having any allergies?" This question is appropriate because the patient's symptoms of pale, grey, and swollen nasal mucosa suggest an allergic reaction. By asking about allergies, the nurse can gather important information to determine the cause of the symptoms. B: "Do you have an elevated temperature?" - This question is not directly related to the patient's nasal symptoms and does not address the likely allergic reaction. C: "Have you had any symptoms of a cold?" - While cold symptoms may present similarly to allergies, the patient's specific symptoms of pale, grey, and swollen nasal mucosa are more indicative of an allergic reaction. D: "Have you been having frequent nosebleeds?" - This question does not directly address the patient's current symptoms and is not likely related to the nasal mucosa appearance described.

Correct Answer: C

Rationale: The correct answer is C: Hydrocephalus. The nurse suspects hydrocephalus due to the symptoms presented by the infant: enlarged cranium, small face, dilated scalp veins, and "setting sun" eyes. Hydrocephalus is the abnormal accumulation of cerebrospinal fluid in the brain, leading to increased intracranial pressure and characteristic physical signs such as an enlarged head. Craniotabes (A) is softening of the skull bones, not associated with these symptoms. Microcephaly (B) is characterized by a smaller head size, opposite to what is described in the question. Caput succedaneum (D) is swelling of the soft tissues of the infant's scalp, which is unrelated to the symptoms mentioned.