nclex practice questions 2023 health assessment

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: B

Rationale: The correct answer is B: parotid gland. The parotid gland is located in front of the ear lobe, and swelling below the angle of the jaw is a common sign of parotid gland inflammation. The tenderness and increasing size of the spot also point towards a parotid gland issue. The other choices, such as thyroid gland (A), occipital lymph node (C), and submental lymph node (D), are incorrect as they are not typically associated with the specific symptoms described by the patient. It is essential to consider the location and function of each structure to arrive at the correct diagnosis.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Head control typically develops around 4 months, so it is normal for a 2-month-old to lack this skill. 2. Reassuring the mother that her baby is within the normal developmental range is important for reducing parental anxiety. 3. Avoiding overly alarming responses helps maintain trust and open communication with the parent. Summary: - Choice B is incorrect as it does not address the mother's concern and may come across as dismissive. - Choice C is incorrect as it may unnecessarily worry the mother and lead to undue stress. - Choice D is incorrect as it introduces a serious and unlikely scenario without evidence at this stage of development.

Correct Answer: D

Rationale: The correct answer is D because dry, flaky cerumen can indicate a change in cilia in the ear canal, potentially leading to conductive hearing loss. This warrants further assessment by the nurse to ensure the patient's aural health is not compromised. A: Eczema lesions typically present differently and are not directly related to dry cerumen. B: While hygiene can contribute to cerumen buildup, dry, flaky cerumen alone does not necessarily indicate poor hygiene. C: Dry, flaky cerumen is not considered a normal finding in a healthy ear and should prompt further evaluation.

Correct Answer: A

Rationale: The correct answer is A: Diabetes. The presence of "cotton wool" or fluffy grey-white cumulus clouds on ophthalmoscopic examination indicates retinal nerve fiber layer infarcts due to microvascular damage, which is a common finding in diabetic retinopathy. This occurs due to ischemia and subsequent axonal swelling. In diabetes, hyperglycemia can lead to damage in the blood vessels supplying the retina, resulting in microaneurysms, hemorrhages, exudates, and ultimately vision loss if left untreated. Summary of other choices: B: Hyperthyroidism - This condition primarily affects the thyroid gland and does not directly cause the characteristic retinal findings described. C: Glaucoma - Glaucoma is a condition characterized by increased intraocular pressure and optic nerve damage, which does not typically present with the specific retinal findings mentioned. D: Hypotension - Low blood pressure may lead to retinal artery occlusion or ischemic optic neuropathy,