nclex practice questions 2023 health assessment

Questions 46

ATI RN

ATI RN Test Bank

nclex practice questions 2023 health assessment Questions

Question 1 of 5

While performing a well-child assessment on a 5-year-old, the nurse notes the presence of palpable bilateral cervical and inguinal lymph nodes. The nodes are approximately 5 cm in size, round, mobile, and nontender. The nurse suspects that this:

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.

Question 2 of 5

The salivary gland that is located in the cheek in front of the ear is the:

Correct Answer: A

Rationale: The correct answer is A: parotid gland. This gland is located in the cheek in front of the ear. It is the largest salivary gland in the human body. The parotid gland secretes saliva into the mouth through Stenson's duct. The other choices are incorrect because Stenson's gland does not exist, the sublingual gland is located under the tongue, and the submandibular gland is located under the mandible. Therefore, the parotid gland is the only gland that fits the description given in the question.

Question 3 of 5

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of the following statements about cerumen is correct?

Correct Answer: C

Rationale: The correct answer is C: The purpose of cerumen is to protect and lubricate the ear. Cerumen, commonly known as earwax, acts as a natural barrier to prevent dust, debris, and microorganisms from entering the ear canal. It also helps to lubricate the skin in the ear canal and prevent dryness and itching. Choice A is incorrect because sticky, honey-colored cerumen is not necessarily a sign of infection; it can occur due to various factors. Choice B is incorrect as the presence of cerumen does not solely indicate poor hygiene; everyone produces earwax regardless of hygiene practices. Choice D is incorrect as cerumen can sometimes block the ear canal and impair sound transmission rather than aid it.

Question 4 of 5

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

Correct Answer: D

Rationale: The correct answer is D because the movement of extraocular muscles is primarily controlled by cranial nerves III, IV, and VI. CN III controls most of the eye movements, CN IV controls the superior oblique muscle, and CN VI controls the lateral rectus muscle. These nerves work together to coordinate eye movements in all directions. Choices A and B are incorrect because age or cataracts do not directly impact the stimulation of extraocular muscles. Choice C is incorrect as CNs I and II are not involved in controlling extraocular muscle movement.

Question 5 of 5

The nurse is preparing to auscultate a patient's enlarged thyroid for the presence of a bruit. A bruit is a:

Correct Answer: C

Rationale: The correct answer is C because a bruit is a soft, whooshing, pulsatile sound best heard with the bell of the stethoscope. This sound indicates turbulent blood flow, often due to a narrowed or blocked artery. Using the bell of the stethoscope allows for better detection of low-frequency sounds like bruits. A is incorrect because a low gurgling sound is not indicative of a bruit. B is incorrect because a loud, whooshing, blowing sound is not characteristic of a bruit. D is incorrect because a high-pitched tinkling sound is not typically associated with a bruit. In summary, the correct answer is C because it accurately describes the characteristics of a bruit, while the other choices do not align with the typical sound of a bruit.

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