nclex practice questions 2023 health assessment

Correct Answer: A

Rationale: The correct answer is A: Heart failure. In this case, the most likely cause of the bilateral pitting edema in the lower legs is heart failure. The pitting edema along with the history of hypertension and coronary artery disease suggests fluid overload due to the heart's inability to pump effectively. The normal skin color, absence of redness or tenderness, and strong peripheral pulses indicate that the edema is not caused by venous thrombosis, local inflammation, or blockage of lymphatic drainage. In heart failure, fluid can accumulate in the lower extremities due to the heart's reduced ability to pump blood efficiently, leading to increased pressure in the veins and subsequent fluid leakage into the surrounding tissues.

Correct Answer: B

Rationale: The correct answer is B: filter out dust and bacteria. The ciliated mucous membrane in the nose traps dust and bacteria present in the inhaled air through the mucus layer and then moves them towards the throat to be swallowed or expelled. This helps in protecting the respiratory system from harmful particles. Choice A is incorrect as the warming of inhaled air is primarily done by the nasal passages and sinuses, not the ciliated mucous membrane. Choice C is incorrect because the filtering of coarse particles is also done by the nasal hairs and the mucous membrane working together, not just the ciliated mucous membrane alone. Choice D is incorrect as the movement of air through the nares is mainly controlled by the size of the nostrils and is not the primary function of the ciliated mucous membrane.

Correct Answer: C

Rationale: The correct answer is C because lymph nodes are accessible for examination in the head and neck, arms, breasts, and axillae. Lymph nodes are present in these areas where they can be easily palpated and assessed for any signs of inflammation or abnormalities. The other choices are incorrect because they do not include all the areas where lymph nodes are accessible for examination. Choice A does not include the axillae, which is a crucial area for examining lymph nodes in the arms. Choice B does not include the axillae and breasts. Choice D does not include the breasts, which are important areas for lymph node examination in cases of breast cancer or other breast-related conditions.

Correct Answer: A

Rationale: The correct answer is A because fixating on an object at 2 weeks is within the expected developmental range. Infants typically develop the ability to follow objects later on. Choice B is incorrect as absence of following light doesn't indicate blindness. Choice C is unnecessary and premature. Choice D is incorrect as the ability to follow objects typically develops around 6-8 weeks.

Correct Answer: B

Rationale: The correct answer is B: the patient can read at 6.1 m (20 ft) what a person with normal vision can read at 9.1 m (30 ft). This is because the Snellen notation 20/30 means that the patient can read at 20 feet what a person with normal vision can read at 30 feet. This ratio signifies the patient's visual acuity compared to a person with normal vision. The other choices are incorrect as they do not accurately interpret the Snellen notation or misinterpret the distance at which the patient can read the eye chart.