nclex practice questions 2023 health assessment

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Bluish lips indicate cyanosis, a sign of inadequate oxygen supply. 2. Dark line along gingival margin suggests lead poisoning. 3. The nurse should assess for other signs of inadequate oxygen supply to determine the severity and underlying cause. 4. This finding is not normal and requires further evaluation to prevent complications. Summary: A: Checking hemoglobin for anemia is not the immediate priority when cyanosis and lead poisoning are suspected. C: Assuming this is a normal finding can lead to overlooking a potentially serious condition. D: Carbon monoxide exposure could be a consideration, but assessing for overall oxygen supply is more crucial in this scenario.

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: A

Rationale: The correct answer is A: parotid gland. This gland is located in the cheek in front of the ear. It is the largest salivary gland in the human body. The parotid gland secretes saliva into the mouth through Stenson's duct. The other choices are incorrect because Stenson's gland does not exist, the sublingual gland is located under the tongue, and the submandibular gland is located under the mandible. Therefore, the parotid gland is the only gland that fits the description given in the question.

Correct Answer: C

Rationale: Step-by-step rationale for why choice C (CN VII) is correct: 1. Palpebral fissures are controlled by muscles innervated by CN VII (facial nerve). 2. Damage to CN VII can result in facial asymmetry, affecting palpebral fissures. 3. CN III (choice A) controls eye movement, not palpebral fissures. 4. CN V (choice B) controls facial sensation, not palpebral fissures. 5. CN VIII (choice D) controls hearing and balance, not palpebral fissures. Summary: Choice C is correct as damage to CN VII affects palpebral fissures due to facial muscle innervation. Choices A, B, and D are incorrect as they do not control the muscles responsible for palpebral fissures.

Correct Answer: C

Rationale: The correct answer is C because the presentation of clear vesicles with an erythematous base around them at the lip-skin border is characteristic of herpes simplex virus 1 infection, commonly known as cold sores. Given the patient's recent travel to Hawaii, exposure to the virus is likely. This infection is self-limiting and typically heals in 4 to 10 days without the need for specific treatment. Choice A is incorrect because seeing a skin specialist may not be necessary for a self-limiting viral infection. Choice B is incorrect as a biopsy is not typically indicated for a clear clinical diagnosis of herpes simplex virus infection. Choice D is incorrect as riboflavin deficiency does not present with clear vesicles and erythema at the lip-skin border.