health assessment practice questions nursing

Correct Answer: C

Rationale: The correct answer is C because the trigeminal (CN V) and the trochlear (CN IV) nerves are indeed stimulated when the outer surface of the eye is stimulated. The trigeminal nerve is responsible for the sensation of touch in the face and controls the muscles involved in chewing. The trochlear nerve controls the superior oblique muscle of the eye, which helps with downward and inward eye movements. Therefore, when the outer layer of the eye is touched or stimulated, these nerves are activated to convey the sensation to the brain. Choices A, B, and D are incorrect: A: The outer layer of the eye is not particularly sensitive to touch compared to other areas like the cornea or conjunctiva. B: The outer layer of the eye is not darkly pigmented; the pigmented layer is actually the uvea inside the eye. D: The visual receptive layer of the eye, known as the retina, is located deeper within the eye, not

Correct Answer: B

Rationale: The correct answer is B. When using an otoscope to assess the nasal cavity, it is crucial to avoid touching the nasal septum with the speculum to prevent discomfort or injury to the patient. Touching the nasal septum can cause pain and potential damage. Incorrect Choices: A: Inserting the speculum at least 3 cm into the vestibule is not necessary and may cause discomfort or injury to the patient. C: Displacing the nose to the side being examined is not required and may not provide any additional benefit during the assessment. D: Keeping the speculum tip medial to avoid touching the floor of the nares is not as critical as avoiding contact with the nasal septum, which is more sensitive and can be easily injured.

Correct Answer: D

Rationale: The signs and symptoms - severe headache, high fever, and neck stiffness - in a young adult point towards meningeal inflammation. The combination of these symptoms is indicative of a potential infection or inflammation of the meninges, the protective membranes surrounding the brain and spinal cord. The presence of fever and neck stiffness, in addition to the severe headache, raises concern for meningitis, an infection of the meninges. This is a medical emergency that requires prompt evaluation and treatment. Other choices are incorrect because: A: Head injury usually presents with a history of trauma, which is not mentioned in the scenario. B: Cluster headaches typically do not present with fever and neck stiffness. C: Migraine headaches do not typically cause such high fever and neck stiffness.

Correct Answer: C

Rationale: The correct answer is C because the trigeminal (CN V) and the trochlear (CN IV) nerves are indeed stimulated when the outer surface of the eye is stimulated. The trigeminal nerve is responsible for the sensation of touch in the face and controls the muscles involved in chewing. The trochlear nerve controls the superior oblique muscle of the eye, which helps with downward and inward eye movements. Therefore, when the outer layer of the eye is touched or stimulated, these nerves are activated to convey the sensation to the brain. Choices A, B, and D are incorrect: A: The outer layer of the eye is not particularly sensitive to touch compared to other areas like the cornea or conjunctiva. B: The outer layer of the eye is not darkly pigmented; the pigmented layer is actually the uvea inside the eye. D: The visual receptive layer of the eye, known as the retina, is located deeper within the eye, not

Correct Answer: A

Rationale: The dry mucosa and deep fissures in the tongue indicate dehydration in the patient. Dehydration causes decreased saliva production, leading to dry mouth and tongue fissures. This is a common symptom of dehydration. The lack of moisture in the oral cavity can result in these physical signs. The other choices are incorrect because irritation by gastric juices typically presents with other symptoms, a normal oral condition would not show these specific findings, and side effects of nausea medication would not directly cause dry mucosa and deep fissures in the tongue. Therefore, the correct answer is A: dehydration.