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: C

Rationale: The correct answer is C: Pull the pinna up and back before inserting the speculum. This is because pulling the pinna up and back straightens the auditory canal, allowing for easier and more accurate insertion of the speculum without causing discomfort or injury. Option A is incorrect as tilting the head forward may obstruct the view. Option B is incorrect as maintaining traction is essential for stability. Option D is incorrect as using the smallest speculum may not provide a clear view or proper insertion depth.

Correct Answer: B

Rationale: The correct answer is B because rubella can indeed damage the organ of Corti in the fetus, which is responsible for hearing. During the first trimester, when the hearing structures are forming, any damage to the organ of Corti can result in impaired hearing for the infant. Choice A is incorrect because rubella can impact the fetus, including the organs responsible for hearing. Choice C is incorrect because rubella can be harmful to the fetus at any stage of pregnancy, not just the second trimester. Choice D is incorrect because CN VIII (the vestibulocochlear nerve) is not directly affected by rubella, rather it is the organ of Corti that is damaged.

Correct Answer: B

Rationale: The correct answer is B: child may have an infection. Enlarged, palpable, mobile, and non-tender lymph nodes in multiple areas suggest an immune response to an infection. In children, common causes include viral or bacterial infections. The size and characteristics of the lymph nodes described in the question are not typical of chronic allergies or a normal finding in a healthy child. Referral for additional evaluation would be premature without first considering the possibility of an infection, which is the most likely cause based on the provided information.

Correct Answer: A

Rationale: The correct answer is A: Red and bulging. In otitis media, the tympanic membrane becomes red and bulging due to inflammation and fluid accumulation. This is an early sign as it indicates increased pressure within the middle ear. Choice B (Hypomobility) is incorrect because it refers to decreased movement of the tympanic membrane, which is not specific to otitis media. Choice C (Retraction with landmarks clearly visible) is incorrect as it suggests the tympanic membrane is pulled inward, which is more indicative of otitis media with effusion rather than acute otitis media. Choice D (Flat, slightly pulled in at the center, and moves with insufflation) is incorrect as it describes a normal or retracted tympanic membrane rather than the characteristic red and bulging appearance seen in otitis media.