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: Correct Answer: B Rationale: 1. Bluish lips indicate cyanosis, a sign of inadequate oxygen supply. 2. Dark line along gingival margin suggests lead poisoning. 3. The nurse should assess for other signs of inadequate oxygen supply to determine the severity and underlying cause. 4. This finding is not normal and requires further evaluation to prevent complications. Summary: A: Checking hemoglobin for anemia is not the immediate priority when cyanosis and lead poisoning are suspected. C: Assuming this is a normal finding can lead to overlooking a potentially serious condition. D: Carbon monoxide exposure could be a consideration, but assessing for overall oxygen supply is more crucial in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Weber. The Weber test has been found to yield unreliable data recently due to its subjectivity and inconsistency in interpretation. The test involves placing a vibrating tuning fork on the midline of the head to assess lateralization of sound. However, factors like bone conduction and individual perception can influence the results, leading to inaccuracies. Romberg test (B) evaluates balance, Whisper test (C) assesses hearing sensitivity, and Audiometer (D) measures hearing thresholds objectively. These tests are more reliable in providing accurate data compared to the Weber test.

Correct Answer: C

Rationale: Step 1: Dark skin may not show cyanosis well, making choice A less reliable. Step 2: Erythema refers to redness, which may not be easily visible in dark skin, making choice B less suitable. Step 3: Palpating for edema and increased warmth allows for a more reliable assessment of inflammation in dark skin, making choice C the correct answer. Step 4: Palpating for tenderness and ecchymosis may be useful but not specific to inflammation assessment in dark skin, making choice D less relevant.

Correct Answer: D

Rationale: The correct answer is D. In an acute infection, such as streptococcal pharyngitis, the tonsils may exhibit yellowish exudates due to bacterial pus formation. This is consistent with the presence of inflammation and infection. Choices A, B, and C describe varying degrees of tonsillar enlargement and white debris, which could be present in different conditions but are not as specific to acute infection. Therefore, the presence of yellowish exudates on the tonsils is the key indicator of an acute bacterial infection like strep throat.