nclex physical and health assessment questions

Correct Answer: C

Rationale: The correct answer is C: decreased ability to identify odors. As people age, their sense of smell tends to decline due to changes in the olfactory system. This is a common phenomenon in older adults and can impact their overall quality of life. The other choices are incorrect because hypertrophy of the gums (A) is not a typical finding in older adults, increased production of saliva (B) is not directly related to aging, and finer and less prominent nasal hair (D) is not a definitive characteristic of older age.

Correct Answer: C

Rationale: The correct answer is C because the characteristics described (bleeding, not healing, ulcerated, indurated base) are indicative of a potential carcinoma, such as squamous cell carcinoma. These features raise concerns about malignancy and warrant immediate referral for further evaluation and management. Choices A, B, and D are incorrect because a benign sebaceous cyst (A) typically presents as a smooth, non-ulcerated mass, Darwin's tubercle (B) is a normal anatomical variation behind the ear and not associated with bleeding or ulceration, and a tophus (D) is a deposit of uric acid crystals seen in gout and would not present in this manner.

Correct Answer: D

Rationale: The correct answer is D because intraocular pressure is primarily determined by the amount of aqueous humor produced and the resistance to its outflow at the angle of the anterior chamber. When there is an imbalance in the production and outflow of aqueous humor, it can lead to an increase in intraocular pressure, which can result in conditions like glaucoma. Choices A, B, and C are incorrect because they do not directly influence intraocular pressure. The thickness or bulging of the lens (A) is related to accommodation for near vision, the posterior chamber accommodating fluid (B) is not a primary factor in determining intraocular pressure, and the contraction of the ciliary body (C) affects the shape of the lens for focusing rather than intraocular pressure regulation.

Correct Answer: A

Rationale: The correct answer is A because vision is not fully developed until around 2 years of age. Newborns have limited visual capabilities and their visual acuity improves over time. Choices B, C, and D are incorrect because infants do not develop the ability to focus on an object at 8 months (B), develop coordinated eye movements by 3 months (C), or have uncoordinated eye movements in the first year of life (D). These statements do not accurately reflect the timeline of visual development in infants.

Correct Answer: C

Rationale: The correct answer is C because the nurse should use the Snellen chart positioned 6.1 m (20 ft) away to assess visual acuity. This is the standard method for testing distance vision. The nurse should ask the patient to read the letters on the chart from the top row down, covering one eye at a time if necessary. This method provides an accurate measurement of visual acuity at a distance. A: Performing the confrontation test assesses visual fields, not visual acuity. B: Using a Jaeger card is for near vision testing, not distance visual acuity. D: Assessing the ability to read newsprint at a close distance does not provide an accurate measurement of visual acuity at a distance.