nclex physical and health assessment questions

Questions 46

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nclex physical and health assessment questions Questions

Question 1 of 5

Jaundice is manifested by a yellow skin colour, indicating rising levels of bilirubin in the blood. Which of the following findings is indicative of true jaundice?

Correct Answer: B

Rationale: Step 1: Jaundice is characterized by a yellow skin color due to elevated bilirubin levels. Step 2: Yellow color extending up to the iris indicates systemic jaundice, involving the whole body. Step 3: Yellow patches throughout the sclera (Choice A) may not indicate systemic jaundice. Step 4: Skin appearing yellow under low light (Choice C) may not be specific to jaundice. Step 5: Yellow deposits on palms and soles (Choice D) are not typical signs of jaundice. Therefore, Choice B is correct as it reflects systemic jaundice, while the other choices do not fully align with the manifestation of true jaundice.

Question 2 of 5

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and a purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has:

Correct Answer: C

Rationale: Rationale: The patient's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, pain in cheeks and teeth, and pain upon palpation all point towards maxillary sinusitis. The maxillary sinuses are located in the cheek area, and infection can lead to the described symptoms. Frontal sinusitis typically presents with forehead pain, and nasal polyps would not cause the specific symptoms mentioned. Posterior epistaxis involves bleeding from the back of the nose and is not consistent with the patient's symptoms. Therefore, the correct answer is C: maxillary sinusitis.

Question 3 of 5

The nurse has discovered decreased skin turgor in a patient. In which of the following would this be an expected finding?

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.

Question 4 of 5

The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the:

Correct Answer: B

Rationale: The correct answer is B: supraclavicular area. Enlarged submental lymph nodes can indicate a systemic issue. Assessing the supraclavicular area is important as it contains Virchow's node, which may indicate malignancy or metastasis. Choices A, C, and D are incorrect as they do not specifically target the area most likely to reveal significant findings related to the enlarged submental lymph nodes.

Question 5 of 5

The nurse is palpating the sinus areas. If they are normal, which of the following would the patient report?

Correct Answer: A

Rationale: The correct answer is A: No sensation. When the sinus areas are normal, the patient should not feel any discomfort or pain upon palpation. This indicates that there is no inflammation or infection present. Choices B, C, and D are incorrect because feeling firm pressure, experiencing pain during palpation, or feeling pain behind the eyes would suggest abnormalities in the sinuses, such as congestion, inflammation, or infection. Therefore, the absence of any sensation is the expected response when the sinuses are normal.

Similar Questions

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