health assessment practice questions

Correct Answer: A

Rationale: The correct answer is A because a smooth, glossy dorsal surface of the tongue is abnormal in adults and may indicate glossitis or nutritional deficiencies. B is incorrect as a thin white coating is normal. Raised papillae (choice C) may indicate transient lingual papillitis but are not typically abnormal. Visible venous patterns (choice D) are normal on the ventral surface.

Correct Answer: C

Rationale: The correct answer is C: Hydrocephalus. The nurse suspects hydrocephalus due to the symptoms presented by the infant: enlarged cranium, small face, dilated scalp veins, and "setting sun" eyes. Hydrocephalus is the abnormal accumulation of cerebrospinal fluid in the brain, leading to increased intracranial pressure and characteristic physical signs such as an enlarged head. Craniotabes (A) is softening of the skull bones, not associated with these symptoms. Microcephaly (B) is characterized by a smaller head size, opposite to what is described in the question. Caput succedaneum (D) is swelling of the soft tissues of the infant's scalp, which is unrelated to the symptoms mentioned.

Correct Answer: D

Rationale: Rationale for Correct Answer D: Tympanostomy tubes are inserted into the eardrum to help drain fluid from the middle ear, relieve pressure, and prevent infections. This is important in children who have recurrent ear infections or fluid buildup. By allowing drainage, the tubes help improve hearing and reduce the risk of complications. Summary of Incorrect Choices: A) Incorrect - Tympanostomy tubes are placed in the middle ear, not the inner ear. B) Incorrect - Tympanostomy tubes are used for conductive hearing loss, not sensorineural loss. C) Incorrect - Tympanostomy tubes are not permanently inserted and are usually removed after a period of time once they are no longer needed.

Correct Answer: B

Rationale: The correct answer is B: It is the most common type of glaucoma. Open-angle glaucoma is indeed the most common type, accounting for about 90% of all glaucoma cases. In open-angle glaucoma, the drainage angle of the eye remains open, but the trabecular meshwork becomes blocked over time. This leads to increased intraocular pressure, which can damage the optic nerve and result in vision loss. A, C, and D are incorrect: A: The symptoms mentioned (sensitivity to light, nausea, halos around lights) are more commonly associated with acute angle-closure glaucoma, not open-angle glaucoma. C: Immediate treatment is not necessarily needed for open-angle glaucoma as it progresses slowly, and treatment can vary based on the severity of the condition. D: Vision loss in open-angle glaucoma typically starts with the loss of peripheral vision, not central vision.

Correct Answer: C

Rationale: Step 1: The described behavior is known as the asymmetric tonic neck reflex (ATNR), a normal infantile reflex. Step 2: The ATNR typically emerges around birth and should disappear between 3 and 4 months of age. Step 3: The reflex helps with hand-eye coordination and development of body awareness. Step 4: Choice A is incorrect as the behavior is not abnormal or related to atonic neck reflex. Step 5: Choice B is incorrect as the reflex typically disappears by 3-4 months, not by the first year of life. Step 6: Choice D is incorrect as it describes a different pattern of movement than what is observed in the ATNR. Summary: The correct answer is C because the behavior described is a normal infantile reflex that typically disappears between 3-4 months of age, aiding in the baby's development.