nclex physical and health assessment questions

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.

Correct Answer: D

Rationale: The Romberg test assesses the maintenance of standing balance by having the patient stand with feet together, arms at the sides, and eyes closed. If the patient sways or loses balance, it may indicate proprioceptive deficits. Conductive hearing loss (A) is related to sound transmission issues in the outer or middle ear, not balance. Lateralization of hearing (B) relates to distinguishing sound direction. Sensorineural loss (C) involves inner ear or auditory nerve damage, not balance. Therefore, the correct answer is D as the Romberg test specifically evaluates standing balance.

Correct Answer: D

Rationale: The correct answer is D. The "soft spot" on a baby's head, also known as the fontanelle, is a normal anatomical feature that allows for the growth and development of the baby's brain during the first year of life. It is a gap between the bones of the skull that eventually closes as the baby grows. Response A is incorrect because the fontanelle is not related to maternal dietary intake during pregnancy. Response B is incorrect as craniosynostosis is a condition where the sutures of the skull close prematurely, leading to abnormal head shape. Response C is incorrect as cretinism and congenital hypothyroidism are not typically associated with the fontanelle. Overall, the correct response, D, provides an accurate explanation of the normal function of the fontanelle in a newborn's development.

Correct Answer: C

Rationale: The correct answer is C: Perform an otoscopic examination of the left naris. The rationale for this is that the child presenting with purulent, malodorous drainage from one naris may indicate a foreign body lodged in the left naris causing infection. By performing an otoscopic examination, the nurse can visualize inside the naris to identify any foreign body or signs of infection. This step is crucial for determining the appropriate treatment plan. Choices A, B, and D are incorrect: A: Referring the child for an antibiotic prescription without further assessment is premature and may not address the underlying cause. B: Having the mother bring the child back in 1 week delays the necessary examination and potential treatment. D: Telling the mother that this is normal without proper assessment could lead to overlooking a potential health issue that requires intervention.

Correct Answer: A

Rationale: The correct answer is A: auricle. The auricle is the visible, outer portion of the ear made up of movable cartilage and skin. It serves to collect sound waves and direct them into the ear canal. The other choices are incorrect because the concha (B) is the concave cavity leading to the ear canal, the outer meatus (C) is the ear canal itself, and the mastoid process (D) is a bony protrusion behind the ear that has no role in sound collection.