nclex practice questions 2023 health assessment

Correct Answer: D

Rationale: The correct answer is D. Performing the otoscopic examination at the end of the assessment is the best approach for a 3-year-old with a suspected ear infection. This allows the child to become familiar with the nurse and the environment, reducing anxiety and increasing cooperation. It also prevents the child from becoming upset early in the examination, making it easier to complete the assessment. Choice A is incorrect because omitting the otoscopic exam based on the presence of a fever could lead to a missed diagnosis. Choice B is incorrect as pulling the ear up and back before inserting the speculum is not recommended as it may cause discomfort and increase resistance from the child. Choice C is incorrect as having the mother leave the room may increase the child's anxiety and make the examination more challenging.

Correct Answer: C

Rationale: Step 1: Dark skin may not show cyanosis well, making choice A less reliable. Step 2: Erythema refers to redness, which may not be easily visible in dark skin, making choice B less suitable. Step 3: Palpating for edema and increased warmth allows for a more reliable assessment of inflammation in dark skin, making choice C the correct answer. Step 4: Palpating for tenderness and ecchymosis may be useful but not specific to inflammation assessment in dark skin, making choice D less relevant.

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: A

Rationale: The correct answer is A: Heart failure. In this case, the most likely cause of the bilateral pitting edema in the lower legs is heart failure. The pitting edema along with the history of hypertension and coronary artery disease suggests fluid overload due to the heart's inability to pump effectively. The normal skin color, absence of redness or tenderness, and strong peripheral pulses indicate that the edema is not caused by venous thrombosis, local inflammation, or blockage of lymphatic drainage. In heart failure, fluid can accumulate in the lower extremities due to the heart's reduced ability to pump blood efficiently, leading to increased pressure in the veins and subsequent fluid leakage into the surrounding tissues.

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.