health assessment practice questions nursing

Correct Answer: C

Rationale: The correct answer is C: turbinates. Turbinates are bony projections in the nasal cavity that increase the surface area for the warming, humidifying, and filtering of inhaled air. Meatus (A) refers to the passages in the nasal cavity, not the projections. Septum (B) is the partition between the nostrils, not the projections. Kiesselbach's plexus (D) is a collection of blood vessels in the nasal septum, not the projections that increase surface area.

Correct Answer: C

Rationale: The correct answer is C: cephalhematoma. A cephalhematoma is a collection of blood between a baby's skull and the periosteum, typically occurring due to trauma during birth. In this case, the lump appeared 8 hours after birth, which aligns with the timeline for cephalhematoma development. It is soft because it consists of blood, and it can increase in size as the blood accumulates. Incorrect Choices: A: Hydrocephalus is an abnormal accumulation of cerebrospinal fluid within the brain, not a collection of blood. B: Craniosynostosis is the premature fusion of skull bones, leading to an abnormal head shape, not a collection of blood. D: Caput succedaneum is swelling of the soft tissues of a newborn's scalp due to pressure during delivery, not a collection of blood.

Correct Answer: B

Rationale: The correct answer is B: acute otitis media. In this case, the presentation of a bright red tympanic membrane and absence of the light reflex are indicative of inflammation and fluid accumulation in the middle ear, which are classic signs of acute otitis media. This condition commonly occurs in young children, especially after a recent upper respiratory infection. Incorrect choices: A: Fungal infection is less likely in this case as the symptoms are more consistent with acute bacterial infection seen in otitis media. C: Rupture of the drum would typically present with sudden relief of pain and discharge from the ear, which is not described in the scenario. D: Blood behind the drum (hemotympanum) is uncommon in children with acute otitis media and would usually be associated with trauma or barotrauma.

Correct Answer: B

Rationale: The correct answer is B: Lyme disease. The presentation of a red circular rash with central clearing, known as erythema migrans, following a hiking trip in the summer is highly indicative of Lyme disease. The specific distribution of the rash across the midriff and behind the knees aligns with typical areas where the rash appears in Lyme disease cases. This rash is a hallmark sign of early Lyme disease caused by the bacterium Borrelia burgdorferi transmitted through the bite of an infected tick. Other answer choices are incorrect because rubeola presents with a different rash pattern, an allergy to mosquito bites would not typically present in this manner, and Rocky Mountain spotted fever typically presents with a different rash appearance and distribution.

Correct Answer: A

Rationale: The correct answer is A. Referring the patient to an ophthalmologist or optometrist is the appropriate action because the patient's inability to read the 20/100 line on the Snellen chart suggests significant visual impairment that requires professional evaluation. Options B and C are incorrect as they do not address the underlying cause of the vision issue. Option B focuses on a different method of assessment and does not provide a solution for the patient's visual acuity problem. Option C assumes the patient's vision issue can be corrected by reading glasses, which may not be the case for a 20/100 visual acuity. Option D is also incorrect as it only adjusts the testing distance and does not address the need for a comprehensive evaluation by an eye care specialist.