health assessment practice questions nursing

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.

Correct Answer: D

Rationale: The correct answer is D because over-the-counter nasal sprays, especially those containing decongestants, can lead to rebound swelling when used for an extended period. Rebound swelling occurs when the nasal passages become more congested after the effects of the medication wear off. This can result in a cycle of dependency on the nasal spray to alleviate symptoms, leading to worsening congestion over time. It is important for the nurse to educate the patient about this potential risk and suggest alternative treatment options to address her allergies effectively without causing rebound swelling. Choices A, B, and C are incorrect because: A: Incorrect, as not all over-the-counter nasal sprays carry a risk of addiction. B: Incorrect, as switching to another brand may not address the underlying issue of rebound swelling. C: Incorrect, as continuous use of the nasal spray without addressing rebound swelling can exacerbate the problem.

Correct Answer: C

Rationale: The correct answer is C: turbinates. Turbinates are bony projections in the nasal cavity that increase the surface area for the warming, humidifying, and filtering of inhaled air. Meatus (A) refers to the passages in the nasal cavity, not the projections. Septum (B) is the partition between the nostrils, not the projections. Kiesselbach's plexus (D) is a collection of blood vessels in the nasal septum, not the projections that increase surface area.

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.

Correct Answer: D

Rationale: The correct answer is D because it provides an accurate explanation for the frequent ear infections in the 2-year-old. The eustachian tube in children is indeed shorter and wider compared to adults, making it easier for infections to develop. This anatomical difference predisposes young children to ear infections. Choice A is incorrect because it falsely implies that frequent ear infections in small children are unusual only if something else is wrong. Choice B is incorrect as checking the immune system is not typically the first step in addressing recurrent ear infections. Choice C is incorrect as cerumen (earwax) does not directly contribute to ear infections in the middle ear.