nclex practice questions 2023 health assessment

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: Red and bulging. In otitis media, the tympanic membrane becomes red and bulging due to inflammation and fluid accumulation. This is an early sign as it indicates increased pressure within the middle ear. Choice B (Hypomobility) is incorrect because it refers to decreased movement of the tympanic membrane, which is not specific to otitis media. Choice C (Retraction with landmarks clearly visible) is incorrect as it suggests the tympanic membrane is pulled inward, which is more indicative of otitis media with effusion rather than acute otitis media. Choice D (Flat, slightly pulled in at the center, and moves with insufflation) is incorrect as it describes a normal or retracted tympanic membrane rather than the characteristic red and bulging appearance seen in otitis media.

Correct Answer: A

Rationale: The correct answer is A: sternomastoid and trapezius. CN XI, also known as the spinal accessory nerve, innervates the sternomastoid and trapezius muscles. The sternomastoid muscle is responsible for neck rotation and flexion, while the trapezius muscle is responsible for shoulder movement and stability. The other choices are incorrect because the omohyoid and sternomandibular muscles are not innervated by CN XI. The spinal accessory nerve does not innervate the omohyoid muscle, and the sternomandibular muscle is not a recognized muscle in the neck. Therefore, choices B, C, and D are incorrect.

Correct Answer: C

Rationale: Step 1: The nurse notices an enlarged and thick skull, which are common signs of acromegaly. Step 2: Acromegaly results from excess growth hormone, leading to changes in facial features. Step 3: Coarse facial features such as enlarged nose, lips, and jaw are classic signs of acromegaly. Step 4: Therefore, assessing for coarse facial features is crucial in confirming acromegaly. Summary: A: Exophthalmos is associated with hyperthyroidism, not acromegaly. B: Bowed long bones are seen in conditions like rickets, not acromegaly. D: An acorn-shaped cranium is not a typical feature of acromegaly.

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.