nclex practice questions 2023 health assessment

Correct Answer: D

Rationale: The correct answer is D: A slight amount of lid lag when moving the eyes from a superior position to an inferior position. In the diagnostic positions test, when the eyes move from an extreme superior position to an inferior position, a slight amount of lid lag is expected due to the normal anatomical structure and mechanics of the eye muscles and eyelids. This lag is a normal finding and not indicative of any underlying pathology. Rationale: A: Convergence of vision in both eyes is not a normal finding in the diagnostic positions test as convergence refers to the inward movement of both eyes towards each other to maintain single binocular vision. B: Parallel movement of both eyes is not a specific finding in the diagnostic positions test. The test is designed to assess the movement of the eyes in different directions. C: Nystagmus in extreme superior gaze is not a normal finding and indicates an abnormality in eye movement coordination, not an expected finding in the diagnostic positions test.

Correct Answer: B

Rationale: The correct answer is B: suspect that the patient has hyperthyroidism. Periorbital edema is a common sign of hyperthyroidism due to the accumulation of fluid in the tissues around the eyes. By suspecting hyperthyroidism, the nurse can further assess for other associated symptoms and recommend appropriate diagnostic tests. Choice A (check for the presence of exophthalmos) is incorrect because exophthalmos refers to bulging eyes, which may be present in hyperthyroidism but is not directly related to periorbital edema. Choice C (ask the patient if he or she has a history of heart failure) is incorrect as periorbital edema is not typically associated with heart failure, which usually presents with generalized edema. Choice D (assess for blepharitis) is incorrect because while blepharitis can cause eyelid inflammation, it is not typically associated with periorbital edema seen in hyper

Correct Answer: D

Rationale: The correct answer is D. Performing the otoscopic examination at the end of the assessment is the best approach for a 3-year-old with a suspected ear infection. This allows the child to become familiar with the nurse and the environment, reducing anxiety and increasing cooperation. It also prevents the child from becoming upset early in the examination, making it easier to complete the assessment. Choice A is incorrect because omitting the otoscopic exam based on the presence of a fever could lead to a missed diagnosis. Choice B is incorrect as pulling the ear up and back before inserting the speculum is not recommended as it may cause discomfort and increase resistance from the child. Choice C is incorrect as having the mother leave the room may increase the child's anxiety and make the examination more challenging.

Correct Answer: C

Rationale: The correct answer is C: "This is a fungal infection caused by all the antibiotics you've received." The black, hairy tongue is a known side effect of prolonged antibiotic use, which disrupts the balance of normal oral flora and predisposes to fungal overgrowth, specifically of the yeast Candida. Antibiotics can eliminate the competing bacteria that normally keep Candida in check. Therefore, the patient's symptoms are most likely due to a fungal infection related to antibiotic therapy, rather than a bacterial issue or temporary overgrowth of hair. Biopsy is not necessary as the condition is commonly seen in this context and can be managed with appropriate treatment for fungal overgrowth.

Correct Answer: D

Rationale: The correct answer is D because the movement of extraocular muscles is primarily controlled by cranial nerves III, IV, and VI. CN III controls most of the eye movements, CN IV controls the superior oblique muscle, and CN VI controls the lateral rectus muscle. These nerves work together to coordinate eye movements in all directions. Choices A and B are incorrect because age or cataracts do not directly impact the stimulation of extraocular muscles. Choice C is incorrect as CNs I and II are not involved in controlling extraocular muscle movement.