health assessment practice questions nursing

Questions 46

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health assessment practice questions nursing Questions

Question 1 of 5

When examining the ear with an otoscope, the nurse would expect to find that the tympanic membrane is:

Correct Answer: B

Rationale: The correct answer is B: pearly grey and slightly concave. This is because a healthy tympanic membrane should appear pearly grey in color and slightly concave in shape. The pearly grey color indicates normal transparency and reflection of light, while the slightly concave shape is indicative of a normal eardrum. Choice A is incorrect as a light pink color and slight bulge are not characteristic of a healthy tympanic membrane. Choice C is incorrect because a pulled-in appearance at the base of the cone of light suggests retraction, which is abnormal. Choice D is incorrect as a whitish color with a small fleck of light is not a typical presentation of a healthy tympanic membrane.

Question 2 of 5

While assessing the tonsils of a 30-year-old, the nurse notes that they look involuted and granular, and appear to have deep crypts. What is the correct follow-up to these findings?

Correct Answer: B

Rationale: The correct answer is B: Nothing, this is the appearance of normal tonsils. In a 30-year-old, tonsils commonly appear involuted, granular, and have deep crypts due to natural aging and exposure to infections. This is considered a normal variant and does not typically require further intervention. Referral to a specialist (Option A) is unnecessary as these findings are within the normal range. Continuing the assessment (Option C) may not yield significant abnormal findings related to the tonsils. Throat culture for strep (Option D) is not indicated unless there are specific symptoms or signs of infection.

Question 3 of 5

Which of the following statements about otoscopic examination of a newborn would be true?

Correct Answer: C

Rationale: The correct answer is C because the normal eardrum of a newborn can appear thick and opaque due to the presence of vernix or desquamated epithelium. Immobility of the drum (Choice A) is not a normal finding in a newborn and could indicate a problem. An "injected" membrane (Choice B) would suggest inflammation or infection, not necessarily infection. The appearance of the membrane in a newborn is not identical to that of an adult (Choice D) as it may have a different color, thickness, or opacity due to developmental differences.

Question 4 of 5

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is:

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.

Question 5 of 5

The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal?

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Bloody or clear watery drainage can indicate a basal skull fracture. 2. Basal skull fractures can cause cerebrospinal fluid leakage, leading to clear watery drainage. 3. Blood in the ear canal can suggest a temporal bone fracture. 4. Assessing for drainage helps identify potential serious head injuries. Summary: A. Incorrect. Purulent drainage indicates infection, not related to head injuries. C. Incorrect. Increased cerumen is not the priority in assessing head injuries. D. Incorrect. Foreign bodies in the canal are not the primary concern in this scenario.

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